PAUL  B.HOEBK 

MEDICAL  BOOKS 

69E.59thSt.,N.Y, 


'I^C'^tiS 


(CnUnnbia  HnturrBitg 
tn  thr  (Citu  at  Nrui  ^nrk 

OluUrgr  af  llbiiairiana  anh  dur«rnna 


SrfrrFitrr   ICtbrary 


SCROFULOSIS 


GERMAN     TUBERCULOSIS    CLASSICS 

Issued  on  the  advice  and  under  the  directioii  of 
EGBERT    MORLAND,    M.D.,  B.Sc. 


SCROFUl.OSIS 


KY 

Prof.     Dr.     G.     CORNET 

BERLIN    AND    REICHENHAI.I. 


Translated  from   the  Second  German   Edition 

I'.V 

J.     E.     BULLOCK,     M.D. 

Assistant  Mcdiial  Officer,  7 lie  Eveisfield  Chest  Hospital, 
St.  Leoiiards-on-Sea 


NEW     \"  O  R  K 

WILLLAM     WOOD     AXD     COMPANY 

MDCCCCXIV 


Digitized  by  the  iiiternet  Archive 

in  2010  with  furiiding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/scrofulosisOOcorn 


PREFACE  TO  THE  SECOND  EDITION, 


The  First  lulilion  of  mv  "  vScrofulosis  "  has  been  exhausted 
for  nearly  seven  years.  Circumstances  have  prevented  my 
following  it  up  sooner  with  a  new  edition.  During  this  time 
many  of  my  observations  have  been  based  on  firmer  grounds 
through  the  assiduous  work  of  numerous  investigators,  and 
many  questions  have  found  new  and  better  elucidation. 

I  hope  this  edition  may  find  as  friendly  a  reception  as  its 
predecessor. 

Professor  Dr.  Georg  Cornet. 


Berlin  and  Reichenhall. 
March,  191 2. 


CONTENTS. 


PAGE 

INTRODUCTION      ...                                                 ..              ...               ..                  .  i 

DISTRIBUTION         ...             .  .              ...              ...                                 .  2 

OCCURRENCE   ACCORDING  TO  AGE   AND  SEX  ...             ...  2 

l.-ETIOLOGY    OF    SCROFULOSIS                                                  ..              ...  5 

I.- Historical  Survey                            ...            ...            ...            ...            ...  5 

NAME               ...            ...             ...             ...             ...             ...             ...  5 

CONCEPTION   OF   SCROFULO.SIS 6 

THE  ACIDITY  OF  SCROFUT,O.SIS  ...             ...             ...             ...  6 

.SCROFULOSIS  AND   TUBERCULOSIS           ...             ...             ...  7 

INJECTION  RESEARCHES 8 

KOCH'S    RESEARCHES           ...             ...             ...             ...             ...  q 

FURTHER      CONFIRMATION      OF      THE      NATURE      OF 

TUBERCULOSIS                 ...             ...             ...             ...             ...  10 

NON-TUBERCULOUS    SYMPTOMS  OF   SCROFULOSIS       ...  12 

II Conception  and  Classification  of  Scrofulosis       ...            ...            ...  14 

A.— EXOGENOUS    CAUSES— CLASSIFICATION    OF    SCRO- 
FULA       15 

Virulence  of  Bacteria  generally  ...            ...            ...            ...  22 

Virulence  of  Pus  Bacteria             ...            ...            ...            ...  22 

Virulence  of  Tubercle  Bacilli      ...            ...            ...            ...  23 

(a)  Attenuated  Virus     ...             ...             ...             ...             ...  23 

{t>)  Bacilli  of  Human  and  Bovine  Tuberculosis  ...             ...  27 

Differences  in  Virulence      ...             ...             ...             ...  31 

Cultural  Differences               ...             ...             ...             ...  31 

Change  of  Type       ...             ...             ...             ...             ...  34 

Significance  of  Bovine  Infection  ...            ...            ...            ...  37 

The  Occurrence  of  the  Bovine  Type  in  Man  ...             ...  ^y 

Bovine  Type  in  Adults         ...             ...             ...             ...  39 

Bovine  Type  in  Pulmonary   Tuberculosis      ...             ...  3Q 

Bovine  Type  in  Mesenteric  and  Cervical  Tuberculosis  41 

Tuberculosis  of  the  Bones  and  Joints           ...             ...  42 

Lupus          ...             ...             ...             ...             ...             ...  43 

B.— THE   ENDOGENOUS   FACTOR— PREDISPOSITION    TO 

SCROFULOSIS                 47 

General   Diathesis              ...            ...            ...            ...            ...  47 

Historical           ...             ...             ...             ...             ...             ...  47 

Modern  Hypotheses — Exudative  Diathesis             ...             ...  49 

Other  Signs  of  Exudative  Diathesis       ...             ...             ...  53 

EN130GEN0US  FACTOR — LOCALIZED  DIATHESIS  ...                ...                ...  60 

.Anatomical  Explanation  of  the  Tendency  of  Scrofulosis  ...  61 

(i)  Permeability  of  the  Skin  and  Mucous  Membranes  62 

(2)  Variation    in    the    Permeability  of   Skin    according 

to    Age            ...             ...             ...             ...             ...  64 

A. — Anatomical  Differences,  64;  (i)  Skin.  64: 
(2)  Mucous  Membranes,  66.  B.— Clinical 
Proofs  of  the  Greater  Permeability  of  the 
Skin  in  the  Young.  66. 

(3)  Different  Permeability  of  Skin  according  to  Sex  ...  71 

(4)  Individual    Differences   ...             ...             ...             ..'.  73 


Vlll 


CONTENTS 


III — Genesis  of  Scrofulosis 

I.— CAUSATIVE  AGENT  OF  PUS 

{a)  Appearance 

(b)  Mode  of   Infection 

II.— TUBERCLE   BACILLI      ... 

.A..— Human  Type    ... 
Occurrence 
Experiments  on  Animals 

(i)  Subcutaneous  Infection 

(2)  Cutaneous   Inoculation 

(3)  Infection  of  the  Mucous  Membranes 

(4)  Intraperitoneal    Infection 

(5)  Intravascular   Infection... 
Clinical  Observations  (Scalp,  86;  Eye,  86;  Mouth  an 

Pharynx,   86;   Teeth,  87;    Nose  and  Ear,  87) 

Law   of   Localization 

Objections  to  the  Law  of  Localization 

Experimental    Errors 
B.— Bovine   Type   ... 

Extent,    Degree,    and    Danger   of   Bovine    Infection 

Opportunities  of  Infection  by  Tuberculous  Meat 

Opportunities  of  Infection  by  Milk  ... 
Tubercle  Bacilli  contained  in  Milk 
Primary  Tuberculosis  of  the   Intestinal   Canal    ... 

Morbid  Anatomy  Experience 

Clinical    Experience 

Collective   Investigation 

The  Difficulties  of  Intestinal   Infection 

Conclusions 

Skin   Infection  through  Bovine  Bacilli 

Infection    of    the    Lungs    and    Bronchial     Glands 
Bovine   Bacilli 

Latent    Foci 
C. — Avi.an  Type 

III.— THE  DIFFERENT  EFFECTS  OF  THE  INFECTION 
The  Histological  Nature  of  the  Tissue 
State  of  Nutrition  of  the  Tissues... 
The  Size  of  the  Micro-organisms  ... 
Biological  Characters 
The  Number  of  the  Bacteria 
Virulence 
The  Closeness  of  Contact 

IV. --THE  DISPERSAL  OF  TUBERCULOUS  INFECTION 
V.-THE  PART  PL.WED  BY  THE  LYMPH  GLANDS 
Anatomical  Protective  Effect  of  the  Lymph  Glands 
Toxic  Protective  Influence  of  the  Lymph  Glands 

VI.— MODE  OF   INFECTION  IN  MAN 

(i)  Relative  Frequency  of  various  Localizations 
(2)  The  Causes  of  Different  Localizations 

Skin     ... 

Murous  Membranes 

IV.-  Infectiousness  of  Scrofulosis  (Spread  of  the  Disease) 


CON'll'iNIS  >X 

PAOK 

v.— Heredity            ...            ...            ...            ...            ...  ...  ...  149 

Till':  JNIII;KITANCE  Ol«"  TUBliKCULOSIS  ...  ...  ...  150 

TRANSMISSION    OF    THE    GKKM    ...             ...  ...  ...  150 

HKRI<:D1TARY  tendency  to  TUMI-RCULOSIS 154 

TRANSMISSION    OK   TIIK   TKNORNCY    TO   SCKOl-'UI.O.SIS  ...  ...  l6l 

VI. — Factors  which  favour  Infection  ...            ...            ...  ...  ...  163 

SOCIAL   POSITION    ...             ...             ...             ...  ...  ...  163 

II.— MORBID  ANATOMY     ..                ...              ...               ...  ...  175 

(i)  PYOGENIC    FORM              ...             ...             ...  ...  ...  173 

(2)  TUBERCULOUS    FORM :  ...  175 

III. -SYMPTOMS     ...              ...              ...              ...              ...  ...  180 

A.— LOCAL  SYMPTOMS  IN  THE  SKIN         .  .  ...  ...  181 

(i)  Non-tuberculous  Form             ...           ...  ...  ...  181 

(2)  Tuberculous  Form       .:.           ...           ...  ...  ...  183 

Lupus                ...            ...            ...            ...  ...  ...  183 

Scrofuloderma                  ...             ...             ...  ...  ...  184 

Tuberculides          ...            ...            ...            ...  ...  ...  184 

Folliculitis        ...             ...             ...             ...  ...  ...  186 

B. —LOCAL  SYMPTOMS  IN  THE  MUCOUS  MEMBRANES  ...  ig3 

Nose          ...           ...           ...           ...           ...  ...  ...  193 

Mouth  and   Pharynx         ...            ...            ...  ...  ...  194 

Ear             ...            ...            ...           ...            ...  ...  ...  196 

Eye            ...           ...           ...           ...           ...  ...  ...  199 

Symptoms  in  the  other  Mucous  Membranes  ...  ...  201 

C— SYMPTOMS   IN   THE   LYMPH   GLANDS  202 

Neck  Glands         ...           ...           ...           ...  ...  ...  202 

Inguinal  and  Axillary  Glands      ...            ...  ...  ...  203 

Bronchial  Glands              ...           ...           ...  ...  ...  203 

Mesenteric  Glands            ...           ...           ...  ...  ...  207 

D.— SYMPTOMS  OF  BONE  AND  JOINT  AFFECTIONS       ...  209 

E.— GENERAL  SYMPTOMS 213 

AN.ffiMIA         ...                 ...                 ...                 ...                 ...  ...  ...  213 

Fever         ...            ...            ...           ...           ...  ...  ...  213 

Nourishment      ...             ...             ...             ...  ...  ...  214 

F.— THE  SCROFULOUS  CONSTITUTION   ...  ...  ...  315 

IV.-COURSE  AND   DURATION  OF  THE  DISEASE  ...  ...  219 

A.— COURSE  OF  PYOGENOUS  SCROFULOSIS  ...  ...  219 

B.— COURSE  OF  TUBERCULOUS  SCROFULOSIS  ...  ...  220 

First  Stage             ...            ...            ...            ...  ...  ...  220 

Second  Stage  (Retrograde  Dispersal,  222)  ...  ...  ...  221 


Third  Stage 
Fourth  Stage 

C— MIXED   INFECTION 
v.— PROGNOSIS    ... 
VI.— DIAGNOSIS     ... 


224 
224 

225 
226 
233 


A.— THE  PYOGENOUS  FORM  ...  ...     233 


X  CONTENTS 

PAGE 

B.— THE  TUBERCULOUS  FORM       235 

(i)  Clinical  Diagnosis        ...           ...           ...  ...  •••  235 

Tuberculosis  of  the  Glands         ...             ...  ...  ...  237 

Tuberculosis  of  the   Bronchial  Glands   ...  ...  ...  237 

Clinical  Differential  Diagnosis                  ...  ...  ...  244 

(2)  Bacteriological  Diagnosis        ...  ...  ...  ■.245 

Proof  of  the  Tubercle  Bacillus  ...             ...  ...  ...  245 

Much's  Granules  ...           ...           ...           ...  ...  ...  247 

Tuberculin  Diagnosis — Allergie  Reaction  ...  ...  ...  250 

Method  OF  THE  Proof  of  Allergie  ...           ...  ...  ...  251 

V.  Pirquet's  Cutaneous  Method  ...             ...  ...  ...  251 

Modification  of  v.  Pirquet's  Method         ...  ...  ...  253 

Ointment   Reaction         ...             ...             ...  ...  ...  253 

Method  of  Using  Moro's  Ointment         ...  ...  ...  253 

Further  Modifications  of  Allergie  Reaction  ...  ...  254 

Intradermic   Reaction     ...             ...             ...  ...  ...  254 

Streak  Reaction               ...             ...             ...  ...  ...  254 

Wolff-Eisner's  Conjunctival    (Ophthalmic)   Reaction  ...  255 

Reaction  in  Other  Mucous  Membranes  ...  ...  ...  256 

Results  of  Allergie  Reaction     ...             ...  ...  ...  257 

A. — Clinical    Tuberculosis    ...             ...  ...  ...  257 

B. — Clinical    Suspects           ...             ...  ...  ...  259 

C. — Clinically   Free   from    Tuberculosis  ...  ...  259 

Subcutaneous  Tuberculin  Test     ...           ...  ...  ...  263 

Allergie  Reaction  in  the  Scrofulous         ...  ...  ...  2C4 

Differentiation  of  the  Human  and  Bovine  Bacillus  ...  265 
Passage  through  Guinea-pigs 
Serum  Culture  ... 
Glycerine   Bouillon   Culture 
Testing  on  Animals 
VII. -PROPHYLAXIS 

I The  Child  in  the  Family  ... 

AIR,  LIGHT,  CLEANLINESS               ..              ...  ...  ...  280 

NOURISHMENT 
Mother's  Milk 
Cows'  Milk 

Milk  and  Food  Preparations 
Faulty  Nutrition — Exudative  Diat 

HARDENING                ...            ...             ...             ...  ...  ...  2qq 

CAUTION  DURING   ILLNESS   IN   THE   FAMILY    ...  ...  300 

DIFFICULTIES  OF  PROPHYLAXIS                ...  ...  ...  302 

Instruction  ...  ...  ...  ...  ...  ••■303 

Dwelling-houses   ...           ...           ...           ...  ...  ...  304 

Institutions  for  the  Care  of  Children      ...  ...  ...  304 

II The  Child  at  School       ...           ...           ...           ...  ...  ...  315 

SCHOOL    BATHS         317 

SCHOOL  FEEDING   ...             ...             ...             ...  ...  ...  318 

SCHOOL  DOCTOR      ...             ...            ...             ...  ...  ...  31Q 

FOREST    SCHOOLS    ...            ...            ...             ...  ...  ...  319 

VIII.-   THERAPEUTICS          ...               ...  .  321 

I.     General   Therapeutics        ..            ...              .  ...  322 

NUTRITION                  ...             ...            ...             ...  .  .  ...  323 

Helps  to  Nutrition           ...           ...           ...  ...  ...  324 


267 
268 
269 
270 

275 
279 


...  283 

...  284 

...  285 

...  291 

hesis    ..  ...  ...  296 


CONTENTS  Xf 

PAGE 

OPEN-AIR   TREATMENT       ...             ...              ■•  •••  •■•  327 

A.-- Climatic  JIkaltii  Rksokts          ...            .•■  •••  •.•329 

B.— MiNKRAi,  Baths              ...            ...            .•■  •  •■  ■••  33« 

EfTect                   ...             ...             •••             •■•  •••  •••  23i 

Indication           ...              ...              •••              ••■  •••  •■•  333 

Mode   of    Use    ...              ...              .••              ••■  ••■  •••  334 

C— Sea  Baths        ...            ...        '   ...           •••  ■•■  •••  337 

Effect                 337 

Indication          ...             ...             ■••             •••  •■•  •  •■  338 

Mode   of   Use    ...             ...             ••.             •••  •••  •••  338 

D.— Sulphur  AND  Arsenic  Springs  ...           ...  ...  ...  339 

E.— Auxiliaries  to  Mineral  and  Sea-bathing  Treatment  ...  340 

F.-  "Choice  of  a  Health  Resort    ...            ...  ...  ...  343 

Climatic  Health  Resorts               ...             ...  ■•■  •••  344 

Watering   Places             ...             ...             ...  •••  •••  34^ 

G.— Holiday    Settlements    and    Children's  Convalescent 

Homes             ...            ...            .••            •••  ■••  •••  349 

Children's  Homes  in  Germany  ...             ...  ...  ...  350 

School   Sanatoria             ...             ...             ...  ...  •■•  359 

H.— Results  in  Mineral  and  Seaside  Convalescent  Homes  ...  361 

I. — Salt  Baths  at  Home      ...            ...            ...  ...  ••■  368 

II Medicinal  Treatment       ...  ...  ...  ...  ...  ...  370 

IODINE  ...  ...  ...  ...  ..■  •••  •••  370 

IRON  ...  ...  ...  ...  ■•■  •••  •••  372 

ARSENIC         375 

CREOSOTE     ...  ...  ...  ...  •••  376 

OTHER  REMEDIES  ...  ...  ...  ...  .-.  .••  378 

TUBERCULIN  378 

Mode  of  Use        ...  ...  ...  ...  ...  ...  383 

CINNAMIC    ACID       385 

SAPO   VIRIDIS  385 

III. — Local  Treatment  ...  ...  ...  ...  ...  ...    388 

A.— SKIN   DISEASES  ...  388 

Eczema       ...            ...  ...            ...  ...  ...            ...  388 

Lupus         ...           ...  ...           ...  ...  ...           ...  393 

Scrofuloderma       ...  ...           ...  ..  ...           ...  399 

Tuberculides          ...  ...            ...  ...  ...           ...  399 

B.— DISEASES  OF  MUCOUS  MEMBRANES  ...  ...  ...  399 

Respiratory  Organs  and  Pharynx  ...  ...  ...  ...  399 

Ear  ...  ...  ...  ...  ...  ...  ...  403 

Eye  ...  ...  ...  ...  ...  ...  ...  409 

C— AFFECTIONS    OF    THE    GLANDS  ...  ...  ...  410 

D.—SCROFULOSIS   OF  THE  BONES  AND  JOINTS  ...  416 

ABBREVIATIONS  USED  IN  THE  BIBLIOGRAPHY  ...  ...  ...  419 

BIBLIOGRAPHY       ...  ..  ...  ...  ...  ...  ...  422 

INDEX  ...  ...  ...  ..  ...  ...  ...  497 

INDEX  OF  AUTHORS  ...  ...  ...  ...  ...  506 


ERRATA. 


p.  40,  line  3  from  bottom,  for  ''  Sabotta,"  rend  "  Sobotta." 

P.  93,  line  ID  from  bottom,  for  •'  Boch,"  read  "  Bock." 

P.   103,  line  4  from  top,  for  "  Goehedini,"  read  "  Gchedini." 

P.  105,  line  7  from  top,  for  "  Bidert,"  read  "  Bicdert";  and  line  7  from 

bottom,  for  "  Sabotta,"  read  ''  Sobotta." 

P.  143,  line  17  from  top,  for  ''  Miiller,"  read  "  Mollcr." 

P.  148,  line  23  from  bottpm,  for  ••  Bierdet,"  read  "  Biedert." 

P.     156,    line    12    from    top,    for    "Martin,    Kircaner,"    read    "Martin 

Kirchner." 

P.  160,  line  7  from  top,  for  "  Mars,"  read  "  Martins." 

P.  187,  line  16  from  top,  for  "  Spindler,"  read  "  Spieler." 

P.   200,   line  4  from  top,  for  "  Hayshi,"  read  "Hayashi";   and  lines  3 

and  4  from  bottom,  o/nit  "  (for  further  information,  see  vol.  .\xi,  ch.  iv,  pp. 

403-406)." 

P.  201,  line  7,  for  "  Eangl,"  read  "  Tangl." 

P.  239,  line  7  from  top,  for  "  Grover,"  read  "  Grober." 

P.  240,  line  14  from  top,  for  "  Bacinsky,"  read  "  Baginsky." 

P.  243,  line  14  from  top,  for  "  Tlan^enga,"  read  "  Platenga." 

P.  246,  line  19  from  bottom,  for  "  Bren,"  read  "  Brem." 

P.  255,  line  3  from  top,  for  "  .\rvonadc,'"  read  "  .Aronade." 

P.   257,   line   7  from  bottom,  for  "  Kictz,"   read  "Krietz";   and   line    12 

from  bottom,  for  "  Pcschorner,"  read  "  Bcschorncr." 

P.  263,  line  16  from  bottom,  for  "  Children  under  10  are  given  o'2 — o'5 

—  I'S  mg., '  read  "  Children  under  10  are  given  o'2 — o"S — i — 5  mg." 
P.  264,  line  3  from  top,  for  "  Hans,"  read  "  Hans  Hans." 
P.  265,  line  9  from  top,  after  "  connected  with  it  "  insert  "  (Citron   and 

others)";  line   10,  after  "contra-indicated"  insert  "or  only  permissible  in 

weak  solutions   (Comby,   i  per  cent.  ;   Baldwin,  3  per  cent.  ;  Citron,  i   per 

cent.,    and    Calmette),    and   even    absolutely    contra-indicated    for    slighter 

cases." 

P.  288,  line  12  from  top,  for  "  Plantcng,"  read  "  Platenga." 

P.  293,  line  17  from  bottom,  for  "  Montin,"  read  "  Monti." 

P.  371,  line  4  from  top,  for  "  Cantini,"  read  "  Cantani." 

P-  ^03^  line  II  from  bottom,  for  "  Balmanns-Squirc,"'  read    '  Balmanno 

.Squire." 


INTRODUCTION 


Although  tlie  discovery  of  ihe  lubercle  bacillus  has  created 
a  true  conception  of  the  nature  of  Tuberculosis,  on  which  to 
construct  a  sure  diagnosis  and  etiology  of  the  disease,  opinions 
as  to  the  nature  of  Scrofulosis  are  still  widely  divergent. 

Some  recognize  in  Scrofulosis  nothing  but  a  slowly  progress- 
ing localized  Tuberculosis,  others  consider  it  an  independent 
disease  from  the  beginning,  due  to  a  certain  disposition  or 
dyscrasia,  which  in  its  course  often  presents  tuberculous  com- 
plications. This  difference  of  conception  explains  the  con- 
tradictory nature  of  the  clinical,  statistical  and  experimental 
reports  which  it  is  not  easy  to  put  in  a  clear  form. 

Step  by  step  we  seem  to  be  coming  nearer  to  this  goal ;  the 
differentiation  of  tubercle  bacilli  of  human  and  bovine  extraction 
has  contributed  to  make  many  phenomena  intelligible  which 
hitherto  have  been  unexplained. 


DISTRIBUTION, 


It  is  almost  impossible  to  form  even  an  approximately  correct 
conception  of  the  disiribtitit)n  of  scroftik)sis.  Tlie  reports  of  older 
writers  do  not  help  us,  because  they  continually  call  struma  and 
other  diseases  scrofulosis. 

Even  at  the  present  time  the  concejMion  ot  scrotulosis  is  loo 
vague  for  us  to  ascribe  to  it  any  special  feature. 

One  doctor  regards  almost  every  acute  superficial  inflam- 
mation or  swelling  of  the  glands  as  scrt)fulosis,  whilst  another 
ascribes  to  it  only  the  affections  of  a  distinctly  scrofulous  nature. 

According  to  Ritter,  among  20,000  children  there  were 
generallv  about  90  per  cent,  with  scrofulotis  symptoms;  according 
to  Volland,  among  2,000  children  about  90  per  cent,  had  also 
scrofulous  s\\elling  of  the  glands  of  the  neck. 

The  statistics  of  mortality  to  which  we  owe  such  valuable 
conclusions  concerning  tuberculosis  of  the  lungs,  do  not  afford 
us  much  information  respecting  scrofulosis.  In  the  Prussian 
statistics,  which  are  otherwise  so  useful,  scrofulosis  and  rickets 
were,  until  1902,  represented  in  common,  and  from  that  time 
onwards,  as  in  the  statistics  of  other  states,  those  suffering  from 
scrofulosis,  who  later  have  died  from  tuberculosis  of  the  lungs 
or  of  bones,  or  of  miliary  tuberculosis,  have  been  included  under 
this  heading.  Owing  to  this  state  of  affairs  I  would  refrain  from 
quoting  statistics  which  would  only  lead  to  false  conclusions. 

D'Espine  has  estimated  the  number  of  deaths  from  scrofu- 
losis, according  to  Lebert,  at  21  per  1,000  of  the  total  mortality, 
and  6  per  1,000  of  the  rich  to  34  per  1,000  of  the  poor.  If  these 
figures  were  correct  one  might  come  to  some  conclusion  about  the 
decrease  of  scrofulosis;  its  extent  in  Ba^•aria  amounts  at  the 
present  time  to  about  5  per  1,000;  in  Prussia  it  forms,  inclusive 
of  rickets,  4  to  5  per  1,000  of  the  general  mortality. 

OCCURRENCE  ACCORDING  TO  AGE  AND  SEX. 

From  clinical  observation  we  are  better  acquainted  with  its 
occurrence  according  to  age  and  sex  than  we  are  with  its  general 
distribution. 


DISTKJJiU'llON  3 

Scrofulosis  is  almosl  exclusively  a  disease  (A  the  period  of 
development,  as  is  conliniied  by  doctors  of  all  times;  it  d<jes  not 
rest  on  any  statistical  error,  like  tin;  theory  of  predisposition  to 
tuberculosis  at  (lie  prime  of  life,  biii  is  f(;unded  on  fact.  As 
it  is  jusl  this  poini  which  is  imi)orlant  for  our  explanatifjn 
of  the  naluic  .'ind  origin  of  scrofulosis  it  refjuires  special 
consideration. 

Of  older  authors  Jiaumes  emphasizes  the  facl  thai  scrofulosis 
hardly  ever  appears  for  the  lirst  time  after  the  i8th  or  20th  year. 
Lebert  places  the  greatest  frequency  betv^'een  the  3rd  and  15th 
year.  Scrofulous  skin  affections  and  otitis  are  very  rare  after 
puberty.  Ruete,  Birch-llirschfeld,  Henoch,  and  others,  also 
more  recent  authors,  say  the  same. 

Its  appearance  in  later  life  rests  on  cjuite  different  conditions  : 
the  so-called  "prison-scrofula,"  from  the  former  unhealthy  state 
of  prisons. 

Sex  influences  its  occurrence  to  a  certain  extent,  and  there 
is  a  preponderance,  even  if  only  slight,  in  the  female  sex^ 
and  greater  frequency  up  to  puberty.  Dolaeus  observes  that 
scrofulous  swellings  occur  oftener  in  the  female  sex 
than  in  the  male,  and  sees  therein  "  a  punishment  for  the 
vanity  of  women  who  love  to  adorn  their  necks  with  all  kinds 
of  jewellery." 

Ruete  and  Wunderlich  expressly  state  that  the  female  sex  is 
oftener  attacked  with  scrofulosis  than  the  male. 

According  to  Garre,  the  relation  of  male  to  female  sufferers 
from  scrofulous  glands  is  as  2  to  3  ;  according  to  Wohlgemuth 
(in  430  cases)  about  12  to  13. 

Unfortunately  as  to  age  and  sex  there  are  onlv  a  few 
researches  of  limited  extent,  the  details  of  which  do  not  afford 
us  sufficient  foundation  on  which  to  base  an  opinion.  As 
fuller  and  more  reliable  examples  we  quote  the  following  : 
Monti,  in  the  Polyclinic  in  Vienna  between  1863  and  1897, 
observed  a  total  of  8,128  scrofulous  children.  Of  these  there 
were  3,880  under  5  years  of  age,  362  under  i  vear  of  age, 
75  infants  under  6  months,  2,107  between  5  and  9,  and  2,141 
between  9  and  14  years  of  age.  Of  these  8,128,  3,731  were  bovs 
and  4,397  girls. 


1  Only  severe  cases  of  bone  and  joint  affections  appear  to  preponderatp 
in  boys,  because  traumatic  causes  occur  much  more  often  than  in  girls. 


SCUOFLLOSIS 


Rabl,    of    Bad    Hall,    during    lUiriy-iwo    years,    observed   in 
hospital  and  private  practice  i  1,796  cases  of  scrofula. 


Age 

Male 

Female 

Tolal 

1-5 

389 

291 

680 

6-10 

2,228 

2,718 

•         4-946 

11-15 

1,642 

2,020 

3,602 

16-20 

417          .. 

694 

1,111 

21-25     .. 

o7' 

279         . 

C)5o 

26-30 

244       .. 

121 

365 

31-40 

'43       •■ 

69          . 

214 

41-50 

88 

54       • 

142 

5 1  -6( ) 

16       .. 

10 

26 

5.540 


6,256 


",796 


Rabl  has  included  cases  of  joint  tuberculosis  in  older  persons 
as  belonging;:  to  scrofulosis ;  this  accounts  for  the  extraordinarily 
high  figures  in  later  years.  One  gathers  from  this  how  much 
the  numbers  depend  upon  the  subjective  impressions  of  the 
observer . 

Both  summaries  founded  on  about  20,000  cases  show  con- 
clusively that  scrofulosis  especially  afTects  children  (over  puberty 
the  numbers  are  much  smaller^),  and  that  especially  in  distinctly 
scrofulous  forms  up  to  15-20  years  of  age  the  number  of  boys 
affected  as  compared  with  girls  is  as  5  to  6. 

In  dealing  with  such  large  numbers  many  errors  must  result 
arising  from  outside  circumstances.  For  reasons  easily  to  be 
understood,  fewer  young  children  are  sent  to  a  place  like  Hall 
than  to  the  general  hospitals  of  a  large  town.  The  smaller  the 
numbers  in  such  statistics  the  greater  the  accidental  sources  of 
error.  Summaries  of  only  a  few  hundred  cases  give  contradictory 
results  and  lead  to  faulty  conclusions  We  can  only  arrive  at  a 
true  result  by  comparing  similar  reports.  In  the  summarv  bv 
Neumann,  who  in  his  Polyclinic  observed  a  total  of  624  scrofulous 
children  (205  under  5  years  of  age,  286  between  5  and  10  and  133 
between  10  and  14),  no  preponderance  of  the  female  sex  was  noted. 

1  The  cases  of  gland  scrofula  mentioned  by  Wohlgemuth  are  as 
follows  : — 

Under  5  years 47"4  per  cent. 

5-10  ,,        ...  ...  20'8  ,, 

10-20  ,,       ...         ...         ...         ...  200         ,, 

Over  20     ,,      ir8 


SECTION     I. 

Etiology  of  Scrofulosis. 


CHAPTER   L 

HISTORICAL    SURVEY. 

NAME. 

The  term  "  Scrofula  "  is  derived  from  the  Latin  scrophula,  a 
translation  of  the  Greek  word  x°''P^'^^  of  the  same  stem  as  a-Kpocfjco 
("  I  grub  up  "),  and  signifies  a  young  pig  (Virchow).  The  reason 
of  the  term  ^otpaSe?,  or  scrophuhe,  lies  in  the  resemblance  which 
the  neck,  enlarged  by  the  swollen  glands  and  forming  a  con- 
tinuous outline  with  the  lower  jaw  and  shoulders,  bears  to  the 
full  contour  of  the  pig's  neck.  Others  attribute  the  term  to  the 
fact  that  the  glands  of  the  pig's  neck  are  particularly  abundant, 
that  pigs  especially  suffer  from  the  disease,  or  that  the  -xpLpahe^i 
are  as  numerous  as  a  pig's  litter.  With  very  little  claim  to  prob- 
ability the  term  has  been  derived  from  the  ^oi/aaSe?,  the  rocks 
at  Tarentum,  the  glands  of  the  neck  in  the  scrofulous  being  con- 
sidered as  irregular  as  the  rocks  in  the  Straits  of  Tarentum. 

The  Latin  term  "  scrophulae  "  was  in  olden  times  and  the 
Middle  Ages  not  often  used ;  'xpipahe<i  was  generally  translated 
by  strumae  (from  strumere,  to  build  up).  Only  in  recent  times, 
chiefly  through  CuUen  and  Huf eland,  the  term  "  Scrofula  "  came 
more  and  more  into  use,  and  the  term  "  Struma  "  was  limited  to 
swellings  about  the  thyroid.  In  England  the  distinction  was  not 
made,  but  rather,  up  to  our  time,  strumous  and  scrofulous  were 
used  as  synonymous  with  scrofulous  and  tuberculous.  The 
French  seldom  used  the  word  struma,  except  in  the  same  sense  as 
we  use  the  word  scrofulous. 

As  an  historical  curiosity  one  may  call  to  mind  the  term 
"  Morbus  regius  "  (King's  evil).  Even  at  the  time  of  Alexander 
Severus  it  was  stated  :    "  Regius  est  vero  signatus  morbus  hie. 


6  SCROFLLOSIS 

quoniam  celsa  curalur  in  aura  "  ("  Sereni  Samon,"  Poem  1>1X). 
In  France,  and  especially  in  l^ngland  (from  the  time  of  Edward 
the  L\)nfessor),  the  power  to  heal  scrofula  hv  huich  was  ascribed 
to  kino-s  and  the  seventh  si)n  in  a  faniil\-,  ilic  formula  being  : 
"  Ja'  roi  U'  idiu-lu',  U'  roi  le  giicrit."  I-'roni  ihc  restoration  of 
Charles  lliill  the  reign  of  Oueen  Anne  tlu'  number  of  persons 
so  treated  was  reckoned  at  100,000.  WHiitt'  was  of  opinion  th.'it 
political  moii\es  underlay  this  treatment,  and  that  onl_\-  such 
illnesses  were  submitted  to  the  touch  of  the  King's  hand  as  were 
so  slight  that  they  often  disappeared  without  any  treatment  at  all. 
Only  in  the  reign  of  Louis  Xl\'  and  w  ith  the  reigning  family 
in  England  respectively,  this  custom  came  to  an  end.  As  the 
King  gave  up  the  practice  of  medicine,  and  the  idea  became  pre- 
valent that  Scrofula  was  inherited,  the  name  "  Morbus  regius  " 
was  lost  and  Scrofula  took  its  place  (White,  \^irchow). 

CONCEPTION  OF  SCROFULOSIS. 

As  to  the  conception  of  the  disease  to  which  we  give  the 
name  of  scrofulosis,  from  the  first  the  importance  attached  to 
changes  in  the  lymphatic  glands  were  taken  into  account,  and 
in  the  last  century  changes  in  other  organs,  such  as  the  skin, 
mucous  membranes,  and  joints.  Besides  the  gland  enlarge- 
ments, older  phvsicians  associated  such  diseases  as  goitre,  carci- 
noma, syphilis,  scabies,  rickets,  &c.,  with  scrofula,  so  that  in 
the  studv  of  these  diseases  one  must  always  distinguish  whether 
one  is  really  dealing  w'ith  those  diseases  which  the  name  indicates. 
Kortum  (1798)  made  a  distinction  between  scrofula  and  struma, 
and  a  little  later  Baumes  separated  glands  which  were  really 
scrofulous  from  swollen  glands  due  to  cold  inflammation  or 
pressure. 

THE  ACIDITY  OF  SCROFULOSIS. 

Older  writers  ascribed  changes  in  the  lymphatic  system  id 
an  idiopathic,  faulty  mixture  of  the  body  fluids,  and  especially, 
since  Cullen's  time,  the  cause  was  thought  to  be  an  acid  sub- 
stance circulating  in  the  blood  (acrimonia  scrophulosa).  Many 
consider  that  scrofula  is  due  to  a  retention  of  semen,  hence  it 
disappears  on  the  outset  of  puberty,  and  they  advise  early  marriage 
as  a  remedy.  Others  attribute  it  to  a  peculiar  venereal  poison, 
others  again  attribute  the  glandular  enlargement  to  some  specific 
change  in  nerve  tissue,  and  especially  to  a  deterioration  in  the 
eighth  pair.  Baumes  holds  the  view  that  it  is  due  to  lymph 
deterioration  ;  according  to  him,  in  scrofulosis  the  lymph  is  faulty 
from   the   first,   although   one   does   not    know   \vhether   the   acid 


MISTORICAI.    SCRVHY  7 

principle;  hy  wliicli  iIk'  lymph  (N'icrioraU-s  is  produccfj  in  thf- 
lymplialic  vessels,  lie  Iivkcs  iIk-  .-uidiiy  lo  ;i  i  hu  l.cnin^^  ot  liie 
lymph. 

Iluleland  considers  dial  s(  rofnia  is  a  local  alTcction,  sirofulous 
disease  (Caclicsia  scroftdosa)  being  a  general  di.sordered  diathesis 
of  the  lymphatic  system,  due  to  atony  and  weakness  of  the  vessels, 
of  which  scrofula  is  only  a  symptom.  Allied  to  reslricled  idio- 
padiic  scrofula  there  is  a  false  or  sympathetic  form,  symptomatic 
of  the  effect  of  another  disease,  such  as  small-pox,  measles, 
syphilis,  injuries,  and  tooili  irriiaiioii.  When,  however,  such  a 
sympathetic  affection  lasts  long  il  can  produce  such  an  over- 
whelming disturbance  of  the  affected  lymph  system  that  it  becomes 
an  independent  disease.  Writers  attribute  changes  in  the  skin 
(eczema,  impetigo),  in  mucous  membranes  (catarrh,  suppuration), 
and  caries  of  bones  and  joints,  to  the  acidity  circulating  in  the 
blood. 

When  humoral  pathology  was  discarded  the  doctrine  of  an 
idiopathic  afTection  of  the  lymph  glands  and  some  peculiar 
scrofulous  substance  lost  more  and  more  adherents.  Broussais, 
Velpeau  and  Piorry  recognized  that  the  scrofulous  gland  affections 
were  secondary  and  resulted  from  changes  in  the  organs  from 
which  the  glands  derived  their  lymph,  namely,  the  skin,  peri- 
osteum and  bones.  Virchow  supported  this  view  with  great 
emphasis. 

SCROFULOSIS  AND  TUBERCULOSIS. 

Originally  the  expressions  scrofulous,  strumous  and  tuber- 
culous were  considered  identical.  Van  Swieten  called  the 
tubercles  of  phthisical  lungs  strumae.  Portal  speaks  of  scrofulous 
phthisis;  tubercle  is  for  him  a  rounded  tumour  containing  scrofu- 
lous matter.  Bayle  (i 774-1816)  considers  tuberculous  phthisis 
a  chronic  specific  disease  of  a  scrofulous  nature,  and  calls  mesen- 
teric scrofulosis  a  mesenteric  tuberculosis.  Hufeland  (1796) 
describes  the  "  frequent  scrofulous  consumption  of  the  lung"  as 
phthisis  scrophulosa,  tuberculosa,  or  scrophulosis  pulmonum,  and 
considers  it  a  metastasis  of  scrofulous  acidity. 

Laennec  most  emphatically  supports  the  identity  of  both 
affections,  seeing  in  scrofula  nothing  more  than  a  localization 
of  tuberculosis  in  gland  structures.  This  theor}^  of  identity 
found  many  supporters.  Lugol  calls  any  patient  scrofulous  who 
suffers  from  tuberculosis.  According  to  him  tubercle  is  a  definite 
structure  having  an  independent  existence  (like  liver,  spleenV 
The  development  of  the  disease,  which  this  constitution  attaches 
to  itself,   embraces  the  whole  life  of  the  individual  and  that  of 


8  SCROFLLOSIS 

his  relations  and  parents.  Rilliet,  Barthez  and  Cruveilbier  were 
also  supporters  of  the  complete  identity  of  the  scrofulous  and 
tuberculous  diathesis;  RokitansUy  considered  tubercle  and 
scrofula  the  same  structures. 

The  most  decided  opposition  to  this  view  came  from  X'irchow. 
He  emphasized  the  necessity  of  considering  the  nature  rather  than 
the  structure  of  the  disease.  The  caseous  material  from  which 
Laennec  argued  is  not  a  specific  substance  which  is  deposited 
and  which  might  be  styled  either  scrofulous  or  tuberculous,  but 
rather  decayed  tissue  material.  Pus  and  typhoid  substances, 
cancer,  and  other  tissues  rich  in  cells  can  also  undergo  a  similar 
metamorphosis.  There  are  thus  several  caseous  substances,  but 
it  does  not  follow  from  their  similarity  that  the  processes  which 
produced  them  are  identical.  Virchow  took  the  specific  character 
of  the  caseous  material  for  tuberculosis,  and  considered  the 
starting-point  of  tuberculosis  to  be  the  tubercle,  a  cellular,  non- 
vascular, heteroplastic  new  formation. 

Scrofulous  new  formations,  according  to  him,  are  not  hetero- 
plastic but  "  irritative  changes  in  tissues  which  sometimes  take 
on  a  hyperplastic,  and  sometimes  an  inflammatory  character." 

Under  scrofula,  in  its  limited  sense,  he  understands  a  disease 
of  the  lymph  glands — there  may  be  ever  so  large  a  circle  of  other 
organic  diseases  included — which  depends  upon  a  weakness  of 
single  parts  or  regions,  or  a  certain  incompleteness  in  the  arrange- 
ment of  the  glands. 

This  dualistic  doctrine  of  Virchow  continually  gained  more 
support,  in  spite  of  individual  opposition  by  Villemin,  but  it 
met  with  a  serious  repulse  after  similar  tubercles  were  described 
by  Koster  in  the  granulations  of  fungous  joint  inflammations, 
by  Schueppel  in  hyperplastic  lymph  glands,  by  Friedlaender  in 
scrofulous  skin  abscesses,  and  always  in  lupus.  Through  Koch's 
discover}-  of  tubercle  bacilli  in  scrofulous  diseases  the  view  of 
the  oneness  of  the  disease  appeared  to  be  again  quite  decided. 

INJECTION   RESEARCHES. 

Long  before  the  discovery  of  the  tubercle  bacilli  a  number 
of  investigators  had  sought  to  establish  the  possibility  of  injec- 
tion of  scrofulosis,  its  nature  and  its  connection  with  tuberculosis. 

Kortum  (1789)  ("  materies  ex  ulceribus  scrophulosis  benignis 
efifluens  "),  Hebreard  (1802),  Salmade  (1805),  Lepelletier  (1816), 
Goodlad  and  Deygalli^res  injected  scrofulous  matter  into  dogs, 
guinea-pigs,  and  a  number  of  healthy  children,  as  well  as  into 
their  own  bodies,  without  anv  result. 


HISTORICAL    SURVKY  9 

It  is  diriicult  lo  trace  tlie  cause  oi  these  negative  results  on 
account  of  tlie  scanty  records  made  of  tliese  ex|)erimenls.  'I'lie 
defective  teclinicjue  w.-is  p.-iilly  I"  hlamc,  p;iril\  ilie  unsuitable 
selection  of  material  and  animals  cliosi^n  for  ilic  injcci  ions,  partly 
also  the  unduly  short  observation  of  tliesf  .-minimis,  or  ilicir  pre- 
mature death  from  oilu-r  diseases. 

Villemin  only  gol  one  positive  result  by  tlie  inj(;ction  of 
matter  from  caseating  lymph  glands  into  two  guinea-pigs  (in 
another  case  he  had  a  negative  result). 

Cohnheim  and  Salomonsohn  reported  miliary  tuberculosis 
of  the  iris  after  the  insertion  of  caseous  particles  from  the  glands 
of  the  neck  removed  from  man  into  the  anterior  chamber  of  the 
eye.  Schueller  reported  tuberculous  joint  affections  after  the 
injection  of  scrofulous  caseating  lymph  glands;  Kiener  and 
Poulet  always  produced  general  tuberculosis  after  the  injection 
of  scrofulous  tissue  substance.  Colas  and  H.  Martin  had  the 
same  experience. 

KOCH'S  RESEARCHES. 

After  the  discovery  of  the  tubercle  bacillus  by  Koch  we 
became  possessed  of  a  sure  criterion  as  to  the  tuberculous  or 
non-tuberculous  nature  of  scrofulous  affections.  The  importance 
of  these  researches  demands  closer  consideration  in  order  that 
we  may  comprehend  the  subject. 

Koch  found  tubercle  bacilli  in  twenty-one  glands,  which 
histologically  were  proved  to  be  tuberculous,  often,  I  admit,  only 
in  small  numbers  and  especially  in  or  about  the  marginal  zone, 
and  twice  only  in  the  interior  of  the  caseous  focus. 

He  found  the  same  thing  constantly  in  thirteen  cases  of  bone 
and  joint  affections,  which,  both  clinically  and  histologicallv,  were 
characterized  as  tuberculous  or  scrofulous  respectively. 

Koch  could  find  no  tubercle  bacilli  in  the  pus  of  one  case 
of  spinal  caries,  but  in  this  case  he  could  produce  tuberculosis 
by  injecting  the  pus. 

In  the  same  way  he  found  tubercle  bacilli  in  four  cases 
diagnosed  as  undoubted  lupus,  in  an  excised  portion  of  skin,  onlv 
once  after  the  twenty-seventh  section,  and  onlv  once  after  the 
forty-seventh  section. 

More  recently,  as  is  well  known,  it  has  been  possible  bv 
the  antiformin  method  in  combination  with  Gram's  stain  ro 
discover  the  bacilli  much  oftener  in  such  structures. 

Further,  from  excised  scrofulous  neck  glands  in  man,  Koch 
has  cultivated  tubercle  bacilli  for  many  months  in  an  artificial 
culture  medium  without  being  able  to  detect  anv  difference  either 


lO  SCROFLLOSIS 

in  their  growlh  or  virulence  from  those  derived  from  a  tuberculous 
lung. 

Finally  he  proved  the  tuberculous  character  of  scrofuKnis 
structures  by  injection  experiments.  Scrofulous  gland  substance 
from  three  cases  injected  into  ten  guinea-pigs  resulted  in  all  cases 
in  marked  tuberculosis,  first  in  the  lymph  glands  in  the  neighbour- 
hood of  the  injection  and  then  in  the  other  organs. 

()nl\-  it  was  discovered  iliai  the  cH)ursi'  of  (he  tuberculosis 
was  verv  slow  on  account  of  the  small  ntimber  of  bacilli  contained 
in  the  injection.  Gland  substance  containing  bacilli  placed  in 
the  anterior  eve-chamber  of  four  rabbits  also  gave  rise  to  the 
following  well-known  appearance  :  tuberculosis  of  the  iris,  casea- 
tion of  the  bulb  and  of  the  neck  glands,  and  tuberculosis  of  the 
lungs.  Inoculation  of  particles  of  tissue  from  six  cases  of  lupus 
into  eighteen  rabbits  and  eight  guinea-pigs  gave  similar  positive 
results,  as  did  also  pus  from  a  tuberculous  elbow-joint  injected  into 
four  guinea-pigs,  and  from  a  case  of  spinal  caries  injected  into 
five  guinea-pigs;  finally  injections  from  lupus  and  a  fungous  joint 
also  from  a  scrofulous  gland  gave  pure  cultures. 

The  opinion  that  Koch  constantly  found  tubercle  bacilli  in 
scrofulous  glands  is  generally  held.  This  opinion,  which  led 
to  quite  false  conclusions,  is  erroneous.  Koch  says  as  follows  : 
"  Altogether  twenty-one  cases  were  examined,  the  glands  of  which 
were  proved  to  be  ttiberculous,"  and  means  by  this,  "  the  presence 
of  epithelioid  cells  which  were  grouped  together  and  enclosed 
more  or  less  numerous  giant  cells."  "  Only  in  glands  which 
had  such  a  tuberculous  structure  could  any  tubercle  bacilli  be 
proved  to  exist.  On  the  contrary  in  a  number  of  cases  in  which 
the  glands  were  enlarged  and  had  partly  become  soft  and  filled 
wMth  pus  foci,  but  in  which  the  epithelioid  cells  and  the  giant  cells 
as  well  as  the  characteristic  tissue  necrosis  were  wanting,  no 
tubercle  bacilli  could  be  found." 

FURTHER  CONFIRMATION   OF   THE   NATURE  OF 
TUBERCULOSIS. 

The  researches  of  Koch  which  formed  the  basis  of  his 
theories  were  repeated  and  confirmed  by  other  authors.  Tn 
fungous  bone  and  joint  diseases  described  as  scrofulous  Demme 
found  tubercle  bacilli  (always  isolated)  in  the  excised  tissues 
fifteen  times  in  seventeen  cases,  whilst  Schuchardt  and  Krause 
found  them  in  twenty-seven  cases  (including  fourteen  tuberculo- 
scrofulous  abscesses),  but  in  the  cases  of  abscesses  only  in  the 
abscess  membrane,  not  in  the  pus.     Muller  found  them  in  thirty 


lUSTOKICAI.   SIRVKY  '  I 

to  thirly-five  cases  at  most.  The  Init.r  l<-avfs  il  an  open  (jucslif^n 
whether  the  negative  cases  ((uiM  n-.i  inrn  oiii  i<>  I)'-  positive  by 
further  search.  Further,  K;m/lcr  IouikI  i  ii1)<t<  |c  Ikk  illi  in  four 
cases,  each  lime  in  the  memhrancs,  ;iii(l  <-i^hi  limes  in  the  secre- 
tions. C'oinil  and  Uahcs,  Killer  and  others  in  seven  cold 
abscesses  wilii  caseous  conlenis  e\-ery  lime,  in  li\e  with  watery 
contents  not  once. 

As  regards  scrofulous  glands,  Deiume  in  twenty-one  cases  of 
glands  undergoing  caseous  degeneration  found  bacilli  twenty  times 
in  the  excised  tissues,  also  isolated  bacilli  in  some  mesenteric 
glands  which  were  hardly  the  size  of  a  pea  and  were  recently 
swollen  and  still  soft;  with  serous  inliltraiinn  (lahcs  mcsaraica) 
Schuchardl  and  Krause  found  them  each  time  in  three  similar 
glands,  also  Cornil  and  Babes,  Albrecht  and  others;  Arloing  by 
injection  (four  times  in  four  cases),  Eve  three  times  in  five  cases. 
Wyssokowitsch,  Pawlowski,  &c.,  had  the  same  experience. 

Demme  found  tubercle  bacilli  in  six  cases  of  lupus,  Doutre- 
lepont  each  time  in  seven  cases  of  excised  tissues,  A.  PfeifTer  in 
conjunctival  lupus  by  means  of  the  microscope,  and  Pagenstecher 
by  injection,  Schuchardt  and  Krause  in  four  cases  of  lupus  and 
tuberculosis  of  the  skin  ;  Albrecht,  &c.,  also  found  tubercle  bacilli. 

Since  then  many  researches  have  been  made  into  the  details 
of  which  we  need  not  enter.  The  fact  that  bacilli  are  often 
found  in  the  tissue  and  in  the  surrounding  zone,  and  much  less 
often  than  in  the  secretions  of  pulmonary  tuberculosis,  explains 
many  negative  results.  That  tubercle  bacilli  are  seldom  found 
in  lupus  has  been  explained  lately  and  its  tuberculous  nature 
further  confirmed  through  the  researches  of  v.  Krueger,  who 
bv  Uhlenhuth's  antiformin  method  (see  p.  247).  in  combination 
with  Gram's  stain,  in  thirteen  cases  constantly  found  the  so-called 
Much 's  tubercle  virus,  that  is  tubercle  bacilli  and  granules  of  bacilli 
which  stain  specially  with  Gram.  As  has  been  already  mentioned, 
this  method  has  now  and  again  apparently  proved  its  utility  for 
detecting  the  presence  of  bacilli  in  other  skin  diseases.  Similarly. 
Harald  Boas  and  Ditlevsen  found  bacilli  in  twenty  cases  by  Gram's 
method  and  in  only  four  cases  by  Ziehl's  method.  The  tuberculous 
nature  of  scrofuloderma  was  proved  bv  Letulla  and  Leloire  by 
injections. 

For  further  details  of  the  tuberculous  nature  of  lichen, 
folliculitis,  erythema  induratum  and  scrofulous  skin  eruptions, 
which  have  only  become  better  kno\\n  within  the  last  few  decades 
through  the  exhaustive  researches  of  Boeck,  and  which  are  rf 
more  significance  for  the  clinical  consideration  of  scrofulosis,  see 
p.  185,  under  the  heading  "  Svmptoms." 


12  SCROFLLOSIS 

NON-TUBERCULOUS  SYMPTOMS  OF  SCROFULOSIS. 

The  investigation  of  peripheral  scrofulous  diseases,  with  the 
exception  of  lupus,  scrofuloderma  and  lichen,  give  different 
results. 

In  scrofulous  eczema,  as  a  rule,  nciiluT  the  histok)gical  signs 
of  tuberculosis  nor  bacilli  are  present.  If  Demme  found  bacilli 
three  times  in  seven  cases  peculiar  conditions  must  have  con- 
tributed to  this  result. 

A  nurse-child,  aged  3^  vears,  had  eczema  of  the  face,  abdomen 
and  thigh.  The  first  three  examinations  for  tubercle  bacilli  made 
within  three  weeks  were  negative.  A  few  days  after  the  last 
examination  the  foster-mother  took  charge  of  a  girl,  aged  7, 
suffering  from  pulmonary  tuberculosis  with  cavities  and  tubercle 
bacilli  in  the  sputum.  Both  children  lived  in  the  closest  inter- 
course in  poor  circumstances  and  in  poverty.  After  about  three 
weeks  tubercle  bacilli  w^ere  found  in  the  eczematous  discharge 
from  the  ear  and  in  the  left  inguinal  region.  The  cervical  and 
the  inguinal  glands,  up  to  this  point  very  little  swollen,  became 
now  markedly  larger,  and  while  the  eczema  had  healed  three 
weeks  later,  one  of  the  inguinal  glands  on  being  excised  w-as 
found  to  be  tuberculous.  After  two  weeks  left-sided  hip  disease 
came  on,  soon  after  which  death  occurred  from  meningitis. 

Ritter's  observations  also  confirm  the  above  rule.  He 
examined  129  cases  of  scaly  and  vesicular  eczema  both  microscopi- 
cally and  by  cultures,  and  in  thirty-four  of  these  cases  by  injec- 
tions, and  found  tubercle  bacilli  only  in  one  child,  whose  health 
was  not  affected  by  disease  inherited  from  the  parents,  and  then 
they  were  only  found  after  many  negative  examinations ;  after 
which  the  eczema  healed.  A  vear  and  a  half  later  the  child,  who 
had  meanwhile  been  brought  up  by  a  phthisical  aunt,  appeared 
again  with  eczema  in  the  right  auricle  and  numerous  bacilli  were 
then  found. 

Martin  could  discover  no  tubercle  bacilli  in  eczema  as  the 
result  of  injections.  Volkmann  found  them  once  in  an  eczema 
of  the  arm. 

In  adenoids,  middle-ear  discharges  and  chalazion  they  were 
found  only  in  a  small  number  of  cases  and,  as  a  rule,  not  at  all 
in  scrofulous  ozasna.  They  appeared  occasionallv  under  peculiar 
circumstances,  as  Demme's  case  shows. 

A  boy,  aged  8  months,  came  as  a  foster-child  into  a  family 
where  the  father  suffered  from  acute  phthisis;  two  months  later 
oz^ena  occurred,  in  the  secretions  of  which  Demme  found  tubercle 
bacilli ;  death  occurred  soon  after  from  tuberculous  meningitis. 


HISTORICAL   SUKVIiY  '3 

Besides  this  bacilli  .'iic-  occasionally  loi.ind  in  llic  )-ellow  crusls 
of  ozojna  which  resenihic  i  iihcrcic  bacilli,  an(J  wliicli  are  arranged 
in  nesLs  (Karlinski,  Alexander).  Vel,  contrary  lo  earber  stale- 
ments,  the  ozajna  had  nolliing  lu  do  with  the  tubercuU;sis. 

According  to  Ritter,  in  the  secretions  of  scrofulous  catarrh 
of  the  nose,  ear  and  eye,  in  138  cliildren  lubercle  bacilb  were 
never  found,  excepting  in  (Morrlux^a  of  two  cbildren  suffering  from 
phthisis;  neitiier  were  they  found  in  L\v(Mny-lhree  children  will) 
acute  muUiple  subcutaneous  abscesses.  Further,  Ritter  examined 
post-niorLem  microscopically,  and  injected  into  guinea-pigs,  matter 
from  the  cervical,  bronchial  and  mesenteric  glands  of  nineteen 
children  who,  during  life,  had  suffered  from  those  "  types  of 
scrofulosis  most  widely  disseminated,"  viz.,  scrofulous  habitus, 
eczema,  otorrhoea,  coryza,  catarrh  of  the  respiratory  tract,  and 
swollen  cervical  and  other  glands;  only  in  one  child  did  lie  find 
tubercle  bacilli. 

In  those  affections  in  which  tubercle  bacilli  were  not  found 
evidence  of  pyogenous  bacteria  was  mostly  present. 

That  catarrh  of  the  respiratory  mucous  membrane  of  the 
nose,  bronchi,  eyes,  ears  and  intestines,  as  far  as  they  did  not 
arise  from  thermal  or  chemical  irritation,  may  be  traced  to  bacteria 
is  well  known.  Of  the  difTerent  forms  of  eczema  the  parasitic  form 
is  accepted  and  proved.  Bacjieria  have  been  proved  to  be  the 
cause  of  phlyctenular  ulcers  by  repeated  experiments.  Burchardt, 
Duclaux  and  Bougeron,  Leber  and  Sattler,  Straub,  have  got 
cultures  of  bacteria,  mostiv  Staphylococcus  pyogenes  aureus  and 
albiis,  therefore  the  same  as  are  found  in  true  eczema,  and  which 
had  a  share  in  producing  vesicular  eruptions  in  animals  experi- 
mented  with. 

Also  in  multiple  skin  abscesses,  which  so  often  occur  in 
scrofulous  children,  Escherich  found  Staphylococcus  pyogenes 
aureus  and  albus.  For  the  tests  of  virulence  of  pvogenic  bacteria, 
see  p.  22. 

To  recapitulate  :  In  cases  of  scrofulosis,  when  dealing  with 
caseating  glands,  bone  and  fungous  joints,  lupus,  and  scrofulo- 
derma, and  the  scrofulides  to  be  discussed  later  (see  p.  183), 
tubercle  bacilli  could  nearly  always  be  found,  thus  the  tuberculous 
nature  of  the  affections  is  assured. 

On  the  contrary,  the  skin  diseases  which  are  reckoned  as 
scrofula,  and  are  characteristic  of  it,  as  a  rule  contain  no  bacilli 
except  those  just  named,  for  example,  eczema,  impetigo,  diffuse 
catarrh  of  the  mucous  membrane,  oz^ena,  &c. ;  thev  also  produce 
no  tuberculosis  by  injection  and  are  at  the  same  time  not  of 
tuberculous  nature,  but  are  caused  hx  pvogenic  bacilli. 


CHAPTER    II. 

CONCEPTION    AND    CLASSIFICATION    OF 
SCROFULOSIS. 


The  term  "  scrofulosis  "  has  met  with  very  various  mean- 
ings and  extensions  in  ihe  course  of  time,  as  we  have  learned 
from  the  historical  introduction.  Originally  associated  with  a 
single  symptom  (the  swollen  neck  glands)  its  significance  has, 
during  the  last  century,  been  much  extended. 

In  the  sense  now  accepted  scrofulosis  comprises  a  complex 
of  svmptoms  almost  entirely  confined  to  childhood  and  early 
youth ;  such  are  on  the  skin  and  the  various  mucous  membranes  : 
lupus,  scrofuloderma,  lichen,  tuberculides,  eczema,  impetigo, 
chronic  blepharitis  and  phlyctenules,  middle-ear  disease,  chronic 
catarrh  of  the  air  passages,  riiinitis,  pharyngitis,  bronchitis,  hyper- 
plasia of  the  tonsils,  catarrh  of  the  alimentary  canals,  and  lastlv, 
certain  affections  of  the  bones  and  joints. 

These  processes  are  not  of  themselves  specific  of  scrofulosis, 
but  are  distinguished  from  other  non-scrofulous  phenomena  of 
the  same  kind  by  :  — 

(i)  Persistency. — Whilst  other  affections  of  the  same  sort 
disappear  comparatively  quickly,  a  scrofulous  affection  is  distin- 
guished by  an  extraordinarily  chronic  course  which  continues 
even  after  the  external  injury  has  passed  off  for  a  long  time. 

(2)  Frequent  Recurrence. — When  the  first  attack  has  subsided, 
a  recurrence  will  often  take  place  without  visible  cause,  at  the 
same  spot  or  elsewhere,  characterized  by  similar  persistence. 

(3)  Multiplicity. — Generally  it  does  not  stop  at  one  single 
affection,  but  similar  or  diverse  affections  appear  in  the  near  or 
remote  neighbourhood,  or  they  may  alternate  with  each  other. 


CONCEPTION  AND  CLASSlllCAJ  ION   OJ<    SCR()H:iJjSlS  15 

A.  -EXOGENOUS  CAUSES -CLASSIPICATION  OF 

SCROFUEA 

In  (lie  palliological  symploiiis  ot  scioliil.-i  vv(;  liavf-  bcf-n  able, 
as  sliown  in  llic  precctlinj;-  cliaplcr,  lo  dcicnnine  two  extraner^us 
causes,  the  tubercle  bacillus  and,  wliere  lliis  is  not  present, 
pyogenic  organisms,  in  the  general  acceptation  of  iIm-  i<-iin,  \iz  , 
staphyk)cocci,  streptococci,  ike.  'J'lie  well-known  pathogenic 
properties  of  tiiese  bacteria  warrants  the  theory  that  ihey  are  not 
accidentiil  or  irrelevant  accompaniments,  biii  (•lini(al  nianifeslati(;ns 
of  scrofula;  the  "  scrofulous  "  character  of  the  disease  refutes  the 
notion  that  they  are  the  jictual  cause  of  scrofula;  thf-y  co-operate 
rather  by  setting  free  and  modifying  both  the  |)urul('ni  bacteria  and 
the  tubercle  bacilli,  and  impress  upon  them  llie  stamp  of  an  idio- 
pathic disease  according  as  one  or  the  other  is  present.  The 
natural  classification  of  scrofulosis  presents  a  tuljerculous  and  non- 
tuberculous  or  purulent  form. 

Undoubtedly  the  tuberculous  form  plays  the  most  important 
part  in  the  class  "  tuberculous  modifications." 

One  cannot  make  much  mistake  if  one  reckons  as  tuberculous 
all  glands  which  are  caseating  and  which  are  easilv  perceptible; 
also  bone  fungus;  in  short,  all  those  severe  and  mostly  widespread 
pathological  processes  which  form  a  field  of  activity,  especially 
for  the  operating  surgeon  or  for  the  morbid  anatomist  on  dis- 
section of  the  bodies  of  those  who  have  died  from  tuberculosis. 
Thus  it  is  that  many  surgeons  and  pathologists,  as  well  as  noted 
specialists,  Velpeau,  Barthez  and  Rilliet,  Neumann,  Soltmann, 
&c.,  are  perfectly  agreed  on  this  point,  and  class  scrofulosis  and 
tuberculosis  under  one  heacfing.  Some,  by  entirelv  setting  aside 
the  idea  of  scrofulosis,  exclude  those  diseases  in  which  tubercle 
bacilli  are  present  from  the  heading  scrofula  and  place  them  under 
that  of  tuberculosis;  whilst  others,  such  as  Escherich,  retain  the 
designation  scrofula,  but  only  to  denote  a  certain  from  of  infantile 
tuberculosis  characterized  by  a  lymphatic  constitution  or  a 
tendency  to  catarrh. 

But  even  if  the  severe,  clinically  most  important,  cases  of 
scrofula  be  allied,  and  numerous  scrofulous  patients  for  clearlv 
perceptible  reasons  (see  p.  20)  turn  out  to  be  tuberculous  sooner  or 
later,  still  the  wide  field  of  scrofula  is  not  by  any  means  exhausted. 

A  second  class  of  complaints  comes  under  this  heading  which 
are  less  severe,  seldom  need  surgical  treatment,  and  still  less 
seldom  cause  death  ;  they  are  principally  afifections  of  the  skin  or 
of  the  mucous  membranes,   inflammation  of  the  eves,  catarrh  of 


l6  SCROI-LLOSIS 

the  middle  ear,  nasal  cavities,  and  the  deeper  sealed  respiratory 
tubes,  hyi)erplasia  of  the  tonsils,  adenoids,  vaginal  discharge 
amongst  girls  (not  of  a  tuberculous  or  gonorrhocal  nature)  and 
chronic  or  transitory  sw^ling  of  the  lymph  glands;  processes 
wliich  justify  no  suspicion  of  tuberculosis  either  histologically  or 
bacleriologically ;  in  which  inoculation  causes  no  tuberculosis, 
and  which,  therefore,  are  not  tuberculous,  though  they  have  for 
generations  been  classed  under  that  head. 

But  still  Escherich  acknowledges  that  even  with  the  constant 
and  characteristic  symptoms  of  scrofula  there  are  no  tuberculous 
changes  to  be  detected.  These  depend  mostly  on  infection,  as 
a  rule  by  pus  organisms,  but  they  are  not  simple  pus  infections 
like  the  adenitis  which  appears  and  disappears  without  any  other 
accompanying  symptoms  in  consequence  of  dental  caries,  for 
example;  but  these  here  mentioned  produce  the  typical  scrofulous 
glands  which  the  triad  of  obstinacy,  multiplicity  and  frequent 
relapses  proves  to  be  of  scrofulous  nature  (see  Ritter  in  der 
Diskuss.,  Bcrl.  kiln.   Woch.,   1907,  p.  261). 

On  the  other  hand,  it  is  not  permissible  to  remove  such 
formations  as  are  demonstrably  tuberculous  from  the  heading 
Scrofula  and  simply  to  place  them  under  that  of  Tuberculosis,  for 
they  differ  essentially,  as  the  clinical  symptoms  characteristic  of 
scrofula  and  the  course,  prognosis,  and  therapeutics  of  tuberculous 
afTections  prove.  But  it  is  just  as  unjustifiable  when  other  authors 
leave  the  non-tuberculous  forms  entirely  out  of  the  scrofulous  class, 
as  Neumann  does,  for  example,  in  chronic  catarrhal  and  purulent 
rhinitis,  all  inflammations  of  the  middle  ear,  all  eczemas,  ulceration 
of  the  skin,  all  the  numerous  abscesses  in  the  subcutaneous  tissues 
of  infants,  and  the  blennorrhagic  affections  of  the  vaginal  mucous 
membranes  in  older  girls,  when  he  denies  them  to  be  of  scrofulous 
character  unless  tubercle  bacilli  are  present. 

This  separation  is  not  justifiable  when  all  these  characteristic 
features  of  scrofula — which  is  generally  the  case — are  present  and 
their  combination  points  to  intimate  connection  with  it.  Also 
the  attempt  to  consider  the  pyogenic  form  as  a  preliminary  con- 
dition of  tuberculosis  is  essentially  without  foundation. 

Kanzler  showed  that  tuberculosis  and  scrofula  are  as  in- 
timately related  to  each  other  as  the  soil  on  which  a  plant  grows 
by  preference  is  to  it.  But  even  Neumann  calls  attention  to  the 
fact  that  "  that  which  Kanzler  and  others  call  soil  on  closer 
inspection  represents  a  part  of  the  plant  itself."  Besides  this, 
every  indication  is  wanting  that  tubercle  bacilli  thrive  better  with 
those  who  have  a  tendency  to  scrofula  or  are  manifestly  scrofulous  ; 
on  the  contrary,  from  a  clinical  point  of  view  it  appears  that  th^ 


CONCEPTION  AND  CLASSIFICATION  OF   SCROl'ULOSIS  I7 

lubcrcle  bacillus  does  noL  llirivc  willi  scrofulous  patienUs,  and  is 
generally  of  a  mi  Id  <  liaracUM-  willi  ili(;ni,'  in  contradistinclion  to 
tuberculous  patients,  and  this  is  a  [xjint  generally  emphasized. 
How  can  these  contradictory  statements  be  reconciled? 

It  is  obviously  a  c^ne-sided  view  to  put  down  the  differences 
in  the  development  of  the  disease  as  due  to  belter  or  worse  foster 
ground,  endogen(jus  factors,  of  which  we  know  little,  instead  of 
studying  the  cause  of  the  disease,  the  exogenous  factor.  Thus  the 
individual  tendency  was  first  made  responsible  for  the  rare  infec- 
tion from  tuberculous  milk  till  Koch  showed  the  difference  in  the 
virulence  of  the  exogenous  factors  of  bovine  and  human  bacilli. 

The  theory  which  is  very  much  advocated,  that  simple  hyper- 
plasia of  the  lymph  glands  must  prepare  the  ground  for  the  tubercle 
bacillus,  can  only  rest  on  the  fact  that  hyperplasial  or  tuberculous 
processes  are  found  together  in  the  glands.  This  state  of  things 
can  be  easily  explained ;  in  consequence  of  peripheral  lesions, 
doors  are  opened  by  which  all  kinds  of  bacilli  can  enter  the  glands, 
and  that  pus  cocci  enter  sooner  and  oftener  than  tubercle  bacilli. 

What  will  happen  then  to  the  non-tuberculous  cases  if  the 
name  scrofula  disappear,  or  if  it  be  restricted  to  non-tuberculous 
phenomena  ?  The  pyogenic  form  of  the  disease  is  a  clinical  entity, 
and  cannot  be  separated  from  scrofulosis  without  destroying  the 
clinical  picture  to  which  we  have  become  accustomed.  It  is  only 
a  different  branch,  which  connects  the  tuberculous  form  with  the 
same  stem  and  root  as  the  scrofulous  tendency. 

I  should  like  to  put  the  question  to  those  investigators  who 
deny  the  pyogenic  form  in  an  inverted  manner. 

(i)  Is  it  not  laid  down  as  a  rule  that  virulent  pvogenic 
organisms  are  immensely  numerous  and  are  very  widely  dis- 
tributed, infinitelv  more  so  than  the  tubercle  bacilli,  that  thev  are 
frequently  found  in  the  dust  of  our  rooms  and  even  on  the  human 
skin,  and  where  an  open  wound  exists  immediatelv  give  proof  of 
their  colonization  and  their  pathogenic  nature? 

(2)  When  scrofulous  children  with  a  tender  skin  or  mucous 
membranes,  or,  as  I  take  it,  have  open  paths  of  entry  and  broad 
lymph  channels  (see  p.  60),  how  can  one  logically  deny  that  thev 
absorb  with  extraordinary  frequency  these  pus  organisms,  with  the 
pathological  consequences  of  increased  local  irritation  and  secon- 
dary glandular  swelling,  on  account  of  increased  susceptibilitv, 
more  frequently  than  normal  children,  and  that,  in  consequence 
of  these  increased  opportunities  for  infection,  thev  repeatedlv 
experience    such    invasions,     and    so    at    last    show    manifestlv 

'  Of  the  cause  of  this  benignity  we  shall   speak  later    (see  p.    45]. 
2 


1 8  SCROFULOSIS 

scrofulous  symptoms,  in  which  case  ii  is  immaicrial  whelher  we 
seek  the  scrofulous  tendency  in  the  increased  receptiblHly  to 
baciUi,  or  in  increased  vuhierabihiy,  or  in  both  ■.•' 

Bui  if  the  pus  organisms  contribute  as  considerably  as  an 
inciting-  factor  in  cases  where  a  scrofulous  tendency  is  present,  as 
tubercle  bacilli  in  parallel  cases,  then  it  is  no  more  than  just  and 
reasonable  to  recognize  their  relationship  by  name,  and  to  use  the 
term  "  pyogenic  scrofulosis."  The  understanding  of  scrofulosis 
can  only  be  advanced  by  this  designation. 

Lately  the  supporters  of  the  identity  of  the  diseases  defend 
von  Pirquet's  theory  of  cutaneous  reaction,  in  contradiction  to  the 
dualistic  idea  favoured  by  myself  and  also  entertained  by  Biedert 
and  others.  It  appeared  at  lirst  as  if  the  question  might  be  easily 
solved  by  the  simple  and  easy  tuberculin  test.  Thus  Escherich, 
who  was  unfortunately  so  early  cut  off,  based  his  theory  on  the 
fact  that  he,  with  Neumann,  Saiga,  Heubner  and  others,  obtained 
cutaneous  reaction  in  all  cases  of  typical  scrofulosis.  He  con- 
siders that  as  a  proof  that,  in  all  children  w'ith  scrofulous  sym- 
ptoms, tuberculosis  has  already  been  established  by  means  of  the 
toxin  allergie. 

But  (i)  these  results  of  von  Pirquet's  tests  received  no  general 
confirmation,  therefore  are  not  conclusive.  Thus  Moro  points  out 
that  negative  results  have  been  obtained  in  a  number  of  cases  in 
spite  of  pronounced  scrofulosis,  in  spite  of  a  scrofulous  constitu- 
tion, in  spite  of  dermatitis  in  the  form  of  chronic  eczema  of  the 
face  and  ear,  impetigo,  lichenous  eruptions,  inflammation  of  the 
eyelids  and  connective  tissue,  of  sw^elling'of  the  Ivmph  glands,  in 
spite  of  external  symptoms  which  exactly  resemble  tuberculous 
scrofula,  and  although  the  patient  was  of  an  age  when  positive 
reaction  appears  and  had  repeatedh'  submitted  to  lli;-  lul^erculin 
test  both  by  friction  and  injection. 

Although  negative  reaction  generally  occurs  amongst  such 
children  in  their  first  year,  yet  the  number  of  older  children  of  5  to 
7  and  II  years  who  do  not  react,  and  who  have  all  the  signs  of 
scrofulosis,  impetigo,  eczema,  vesicular  eruptions,  and  swollen 
neck  glands  (Moro),  confirms  the  old  experience  that  not  all 
scrofulous  patients  are  tuberculous,  and  that  scrofulosis  cannot  be 
identified  with  tuberculosis. 

The  phenomenon  that  negative  tuberculin  reaction  among 
tuberculous  patients  in  later  childhood  becomes  positive  is  easilv 
explained.  It  is  the  exact  parallel  of  a  similar  observation  among 
the  non-scrofulous;  that  is  to  say,  it  is  explicable  In-  tlie  fact  that 
many,  and  perhaps  most,  scrofulous  patients,  especially  among 
the  poorer  classes,  have  plenty  of  opportunities  in  the  course  of 


CONCKPTION    AND   CLASSIFICATION  OI-    SCKOMJLOSIS  I9 

yeai'S  of  laking  up  lubcrclc  bacilli  of  llic  liunlan  and  bovine  lype 
and  become  tuberculous  either  decidedly  or  in  a  modified  form, 
and  exhibit  allergic  and  positive  tuberculin  reaction. 

Such  infection  by  tubercle  bacilli,  as  well  as  by  pus  cocci, 
amongst  those  with  a  jjredispc^sition  to  scrofulosis  is  all  the 
more  probable  and  all  the  more  frequent  because  they  appear 
anatomically  to  be  especially  predisposed  to  it  because  of  the 
ready  means  of  access  and  the  easier  dispersal  of  the  bacteria 
(see  pp.  63  and  70),  but  this  is  particularly  the  case  amongst  those 
suffering  from  scrofulosis  in  which  impetigo,  eczema,  &c.,  have 
left  open  paths  for  the  entry  of  bacteria. 

If  such  children  exhibit  a  positive  tuberculin  reaction,  still  it 
is  not  because  their  scrofulosis  (which  had  made  its  appearance 
much  earlier)  (see  Moro  above)  was  from  the  beginning  of  a 
tuberculous  nature;  on  the  contrary,  the  counter  evidence  lies  in 
the  former  negative  reaction. 

(2)  In  the  exposition  of  von  Pirquet's  reaction  there  is,   as 
unfortunately  often  happens,  an  undercurrent  of  error  which  has 
hitherto  not  received  attention,  and  which  has  led  to  quite  false 
notions  on  other  questions.     Positive  reaction  was  put  down  to 
clinically  evident  scrofulous  phenomena  which,  though  so  appar- 
ently conclusive  and  seductive,  were,  a  priori,  baseless ;  positive 
cutaneous  reaction  proves  nothing  more  than  that  a  tuberculous 
centre  is  or  was  in  the  body  which  caused  allergie ;  as  to  where 
this  centre   lies   it   leaves   us   completely   in   the   dark,   unless   a 
distinct  local  reaction  take  place  in  the  very  centre  of  the  disease. 
Now  it  is  indisputable  that,  amongst  those  who  react  posi- 
tively  quite   independently   of   their  scrofulous   symptoms,    their 
eczema,  their  impetigo,  their  vesicular  eruptions,  and  later  swell- 
ing of  the  neck  glands,   there  are  some  who  have  tuberculous, 
bronchial,  or  mesenteric  glands  and  thus  react,   so  the  tubercu- 
lous character  of  their  evident  scrofulosis  was  only  deceptive ;  such 
are  not  isolated  cases  to  which  no  importance  need  be  attached, 
and  which  do  not  enter  into  the  calculation,   but  they  are,   and 
must  be,  tolerably  frequent  and  form  a  considerable  percentage. 
It  may  be  presented  statistically. 

(i)  Persons  suffering  from  scrofulosis  (i.e.,  the  pvogenic 
form)  are  exposed  to  the  same  sources  of  infection  as  the  non- 
scrofulous,  such  as  infection  by  particles  of  sputum,  or  bv  milk 
containing  tubercle  bacilli,  which,  notwithstanding  their  slight 
virulence,  are  frequently  sufficient  to  create  a  small  centre  which 
then  causes  allergie. 

(2)  They  will  thus  develop  with  at  least  the  same  frequencv 
as   the    non-scrofulous,    bronchial    and    mesenteric   glands  (as   to 


20  SCROFULOSIS 

wheiher  slightly  ur  highly  viiuleiu  we  will  speak  hereafter)  which 
have  not  the  slightest  causative  connection  with  the  scrofulous 
symptoms  visibly  present  on  the  skin  and  in  the  neck  glands 
and  perhaps  also  never  appear  in  connection  with  them.  But 
Heubner  himself  acknowledges  that  he  has  never  dissected  a 
child  sufl'eririg  from  genuine  scrofula  which  was  w'ithout  tuber- 
culous bronchial  glands.  Such  children  would  evidently  react 
positively  during  life  on  account  of  their  tuberculous  bronchial 
glands,  and  would  then,  according  to  the  above  view,  in  spite 
of  their  genuine  tuberculous  condition,  if  they  have  external 
scrofulous  symptoms,  be  wrongly  classed  as  tuberculo-scrofulous. 

(3)  Those  suffering  from  pyogenic  scrofulosis  would,  on 
account  of  their  increased  susceptibility  to  bacterial  infection, 
exhibit  tuberculous  bronchial  and  mesenteric  glands  much  more 
frequently  than  persons  normally  developed.  I  will  not  insist 
further  on  this  point,  but  base  my  proofs  on  facts  which  are 
universall}'  acknowledged. 

Thus,  as  the  non-scrofulous  act  positively  to  von  Pirquet's 
test,  simply  on  account  of  their  bronchial  and  mesenteric  glands 
without  having  any  other  tuberculous  centre,  sufferers  from 
pyogenic  scrofulosis  must  react  positively  with  at  least  equal 
frequency  and  with  an  equal  percentage  from  the  same  cause 
without  the  presence  of  other  tuberculous  centres,  that  is  to  say, 
without  the  symptoms  on  their  skin  and  in  their  neck  glands 
being  in  any  way  connected  with  their  latent  tuberculosis,  and 
without  the  manifestly  scrofulous  symptoms  being  tuberculous. 

Thus  if  Moro,  for  example,  had  found  amongst  300  cases  of 
scrofulosis  13  (4"3  per  cent.)  with  decided  scrofulosis  but  negative 
reaction,  the  result  would  be  considerably  changed  if  it  were 
possible  to  strike  out  of  the  remaining  287  all  those  who  have 
solely  tuberculous,  bronchial  and  mesenteric  glands  indepen- 
dently of  their  scrofulosis,  and  who  exhibited  allergic  only  on  that 
account.  Weber  (Heft  42)  found,  for  example,  that  the  inoculation 
of  a  caseating  mesenteric  gland  caused  tuberculosis  in  a  scrofulous 
child,  but  that  inoculation  of  swollen  neck  glands  did  not  prove 
tuberculosis.  Thus  tuberculin  cannot  decide  whether  the  scrofu- 
losis is  of  a  tuberculous  nature  unless  there  be  at  least  decided  local 
reaction. 

The  latent  bronchial  and  mesenteric  glands  mav  indeed  have 
been  caused  through  the  influence  of  the  scrofulous  predisposition, 
but  who  ran  prove  in  a  single  case  that  this  is  so?  In  anv  case 
not  those,  as  numerous  observations  prove,  who  exhibit  no  trace 
of  scrofulosis,  though  latent  centres  mav  exist. 

The  results  obtained  by  cutaneous  reaction,   the  importance 


CONCIiPTlON    ANIJ   CLASSII' ICATION  OF    SCROFLI.OSIS  2  1 

of  wliicli  resls  on  oLiicr  grounds,  an;  in  no  way  aj^plii  able,  and 
can  under  no  circumstances  destroy  iIm;  ilieory  tliat  pyogenic 
scrofulosis  is  a  division  of  general  scrofulosis,  and  il  is  quite 
unautlKM'ized  when  Moro,  Kschericli,  &c.,  lay  stress  on  the 
collaboration  of  a  diathesis  with  ihe  tuberculous  infection  as  the 
cause  of  scrofulosis,  while  they  ignore  or  plare  in  the  bncl-iground 
other  branches. 

That,  besides  bacteria,  other  exogenous  evils  can,  where  pr«^- 
disposition  is  present,  excite  not  only  single  symptrjms,  but 
clinically  prove  scrofulosis,  is  a  supposition  that  must  appear 
doubtful.  Amongst  such  evils  are  cold  in  the  respiratory  mucous 
membrane,  toxic  and  alimentary  troubles,  excess  of  metabfjlism  in 
the  digestive  canal,  mechanical  and  chemical  irritation  (but  these 
come  under  the  head  of  bacteria  in  the  broader  sense  of  the  term). 
Pfaundler  goes  so  far  as  to  consider  every  non-physiological 
irritation  of  the  cells  as  a  possible  exciting  cause.  But  up  to  the 
present,  at  least,  there  are  no  proofs  on  which  to  base  this  theory. 

Such  irritation  may,  perhaps,  amongst  sensitive  children, 
cause  temporary  reaction,  which  of  itself  is  sufficient  to  facilitate 
the  entry  of  the  bacteria  and  even  promote  it  and  thus  forms  a 
favouring  medium,  but  this  irritation  is  certainly  not  sufficient 
to  produce  typical  and  classical  scrofulosis  with  all  its  character- 
istics; which  leaves  plenty  of  scope  to  subjective  opinion  in  fixing 
its  limits ;  for  this  presupposes  microbes  which,  when  thev  have 
forced  an  entrance,  become  active  agents  through  their  multi- 
plication, and  are  capable  of  maintaining  the  process  (obstinacy, 
recurrence). 

We  find  a  confirmation  of  our  opinion  in  the  proof  given  by 
pus  organisms,  which,  as  a  rule,  easily  enter  the  scrofulous  foci. 
Also  observation  of  the  diseases  of  the  lymphatic  glands, 
when  there  is  apparently  no  disease  of  the  tributary  area,  or  a  tem- 
porary advance  beyond  it,  does  not  contradict  this  opinion,  as  a 
very  satisfactory  explanation  may  be  found  (see  pp.  63,  64,  67 
and  81). 

We  have,  therefore,  to  distinguish  the  following  forms  of 
scrofulosis  : — 

(i)  The  tuberculous  form  due  to  the  tubercle  bacillus. 

(2)  A  non-tuberculous  form  caused  by  other  bacteria. 
According  to  our  present  knowledge  they  are  mostlv  the  staph  v- 
lococcus  (aureus  and  albus)  or  the  streptococcus.  To  simplifv  the 
matter,  T  should  like  to  propose  the  term  "  pvogenous  form," 
but  we  must  always  remember  that  it  does  not  alwavs  go  so  far 
as  the  formation  of  pus,  but  the  process  is  often  arrested  in  the 
first  stage  of  inflammatory  swelling,  and  the  pus,  which  is  to  a 


22  SCROFULOSIS 

certain  extent  properly  a  linal  product,  engenders  the  bacteria 
which  cause  it.  This  term  may  be  used  in  the  same  sense  as 
when  we  class  caseating  pneumonia  as  tuberculous,  although 
there  are  often  no  typical  tuberculous  formations.  To  these  we 
may  add  :  — 

(3)  A  combination  of  both  processes,  the  tuberculous  and  ihe 
pvogenous,  the  mixed  form  of  scrofulosis,  the  effects  of  which 
differ  according  as  the  tubercle  bacillus  or  other  germs  come  into 
play  first  or  simultaneously. 

How  frequently  the  tubercle  bacillus  and  other  bacilli  are 
concerned  in  scrofulous  modifications,  in  the  glands  for  instance, 
is  shown  by  the  researches  of  v.  Brunn,  who  could  prove  that  in 
thirty-nine  cases  of  tuberculous  neck  glands  there  were  strepto- 
cocci in  twenty-eight  of  them. 

Therefore  scrofulosis  is  a  pyogenous  or  mixed  tuberculous 
infection  arising  from  a  special  diathesis  (predisposition) — vide' 
next  chapter. 

VIRULENCE  OF  BACTERIA  GENERALLY. 

Having  acknowledged  that  bacteria,  as  outward  factors,  play 
a  considerable  part  in  the  genesis  of  scrofulosis,  we  must  recog- 
nize the  necessity  of  knowing  more  of  their  pathogenic  qualities 
and  virulence. 

VIRULENCE  OF  PUS  BACTERIA. 

It  has  long  been  known  that  the  virulence  of  bacteria 
fluctuates  within  very  wide  limits;  from  the  trifling  almost  sapro- 
phytic activity  and  medium  virulence,  which  is  most  widely  dis- 
seminated to  the  highly  virulent  forms  which  induce  a  speedy 
breaking  down  of  the  tissues.  This  is  corroborated  by  the 
extremely  slow  course  of  the  maladies  wdiich,  even  in  the  pyo- 
genous form  of  scrofulosis  (apart  from  the  different  power  of 
resistance  of  the  organism),  frequentlv  does  not  go  so  far  as  the 
formation  of  abscess,  but  spontaneous  retrogression  occurs;  from 
time  to  time,  however,  a  more  or  less  speedy  suppuration  in  the 
tissues  is  induced. 

One  considerable  difficulty  in  the  investigation  of  the  scrofu- 
lous processes  lies  in  the  fact  that  the  test  of  virulence  of  the 
staphylococci  in  the  animals  experimented  on  does  not  always 
lead  to  reliable  results,  as  we  know  from  experience  that  man  is 
more  susceptible  to  these  bacteria  than  animals,  therefore  no 
certain  conclusions  can  be  drawn.  The  most  suitable  animal  for 
such  experiments  is  the  rabbit,  and  the  best  method  is  the  intra- 
venous injectir)n  of  bouillon  cultures,  so  as  to  combine  the  action 


CONCIiPTION   ANIJ  CJ,AS.S1J' JCATIOxN  OF   SCROFULOSIS  23 

of  Llie  toxins  alrciidy  lonned  vviLli  the  action  ot  die  living  bacteria. 
A  rather  virulent  strain  of  a  bouillon  culture  (jf  one  day's 
growth  in  an  intravenous  injection  will  kill  a  medium-sized  rabbit 
in  from  four  to  eight  days;  many  animals  have  great  powersi  of  re- 
sistance; many  are  even  refractory.  The  eye  of  the  rabbit  exhibits 
a  high  degree  of  sensitiveness;  a  tiny  scrjitch  with  a  needle  which 
lias  been  infected  with  staphyl(j(:(jcci  produces  opaciiy  f;i  the 
cornea  (Leber).  Subcutaneous,  and,  better  still,  ini ramus' ular, 
injections  lead  to  positive  results  willi  rabbiis,  whilst  cutaneous 
injections  fail  entirely. 

The  virulence  appears  to  increase  with  its  passage  through 
the  animals.  The  ferment  and  poison  production  do  not  run 
parallel  with  the  widely  varying  limits  of  the  virulence,  the 
formation  of  the  poison  can  entirely  disappear  without  any  appre- 
ciable diminution  of  the  virulence  (see  Neisser  and  Lipstein, 
"  Handb.  f.  Path.  Aiikr.,"  third  edition,  p.  124). 

For  the  influence  of  injury  to  the  primary  tissues,  see  below. 

To  draw  conclusions  for  man  from  the  pathogenicity  of 
animals  is  also  unreliable  in  the  case  of  streptococci.  A  test 
of  virulence  is  made  with  fresh  bouillon  cultures  (alkaline 
meat  bouillon  with  i  per  cent,  peptone  "Witte),  but  without 
the  addition  of  grape  sugar,  because  this  increases  the  growth ; 
but  it  has  an  adverse  effect  on  the  virulence  (see  Lingelsheim). 

Naturally,  only  fresh  cultures  can  be  employed  because  their 
virulence  decreases  rapidly ;  it  is  best  retained  in  a  mixture  of 
serum  bouillon  and  in  gelatine  puncture.  It  increases  in  its 
passage  through  animals.  Rabbits  injected  cutaneouslv  near  the 
root  of  the  ear,  and  mice  injected  in  the  skin  at  the  root  of  the  tail, 
are  specially  adapted  for  these  experiments,  whilst  guinea-pigs  are 
unsuitable.  Should  doubt  still  exist  as  to  the  virulence,  peritoneal 
injections  are  employed,  Avhen  it  will  be  found  that  still  virulent 
cultures  will  lead  to  death  in  eight  days  in  the  case  of  mice  with  a 
dose  of  o"5  to  i"o  c.c,  and  in  the  case  of  rabbits  a  dose  of  from  5*9 
to  io"9  c.c.  (see  Lingelsheim). 

VIRULENCE  OF  TUBERCLE   BACILLI. 

(a)  Attenuated   Virus. 

j^fter  we  have  been  able  to  prove  in  a  number  of  scrofulous 
foci  that  tubercle  bacilli  have  been  the  cause,  we  must  be  struck 
with  the  generally  slow  course  of  such  diseases  in  the  skin,  the 
glands,  and  the  joints,  in  contrast  to  the  relativelv  speedv 
destruction  of  tuberculous  processes  in  other  places,  especially 
pulmonary  tuberculosis  in  persons  of  the  same  age. 


24  SCROFULOSIS 

This  was  endeavoured  to  be  explained  by  the  supposition 
that  among  scrofulous  persons  there  was  a  weakened  virus.  But 
no  exact  proof  has  been  fordicoming.  Arloing  indeed  stated  that 
when  he  inoculated  scrofulous  glands  into  rabbits  he  could  only 
obtain  local  foci  at  the;  place  where  he  had  injected,  but  no  tuber- 
culosis, whilst  inoculated  guinea-pigs  suffered  from  general  tuber- 
culosis. On  the  other  hand,  Koch  and  others  successfully 
inoculated  rabbits  with  matter  from  scrofulous  glands  and  lupus, 
and  do  not  mention  such  failures.  Eve  also  succeeded  in  pro- 
ducing general  lu]3ercul()sis  three  times  out  of  five  by  inoculating 
rabbits  with  scrofulous  glands. 

1  have  also  repeatedlv  inoculated  guinca-jiigs  with  lupus 
matter  or  Ivmph  glands  dependent  on  lupus,  and  transferred  the 
resulting  tubercles  into  other  guinea-pigs  in  the  most  widely 
different  organs,  without  being  able  to  distinguish  the  least 
difference  in  these  results  and  those  obtained  from  sputum. 

As  I  have  already  remarked  in  my  first  edition,  I  can  state 
from  mv  own  experience  that  animals  inoculated  with  scrofulous 
organs  exhibit  in  general — but  not  always — a  longer  course  of 
disease  than  those  inoculated  with  sputum  or  cultures.  But  we 
must  not  necessarily  seek  the  cause  for  this  in  the  weakening  of  the 
bacilli,  but  it  may  rather  be  explained  by  the  fact  that  the 
inoculated  particles  of  tissue  may  have  contained  a  trifling 
number  of  bacilli,  for  it  is  clear  that  the  quantity  of  germs  must 
have  an  influence  on  the  sort  of  infection  and  its  course,  especially 
with  bacilli  of  such  slow  growth  as  the  tubercle  bacillus.  This 
relative  dependence  of  the  success  of  the  inoculation  on  the 
quantitv  of  bacilli  has  been  much  too  highly  rated  by  many, 
especiallv  bv  Bollinger  and  his  school,  on  the  ground  of  so-called 
.attenuation  experiments  which  have  been  completely  insufficient. 

These  attenuation  experiments  of  Gebhardt,  Bollinger's  pupil, 
formerlv  so  much  quoted,  were  in  no  way  capable  of  settling  the 
question.  For  the  result,  that  animals  which  had  been  inoculated 
with  highly  diluted  milk  (r  :  i,ooo)  from  tuberculous  cows  remained 
healthv,  whilst  the  milk  was  pure  or  contained  only  i  :50 
attenuated  tubercles,  is  no  proof  that  such  diluted  milk  is  innocu- 
ous, for  milk  from  healthy  udders  (as  in  Gebhardt's  case)  will  as 
a  rule  rarely  contain  bacilli,  and  if  it  does  there  will  be  but  few, 
so  the  presence  of  living  bacilli  in  the  selected  attenuation  of 
I  :  I, GOG  is  questionable. 

It  is  the  same  with  Gebhardt's  further  experiments.  Ex- 
periments on  animals  with  attenuated  sputum  up  to  i  :ioo,ogo 
infected  subcutaneously,  interperitoneally,  or  by  inhalation  had, 
without  exception,   no  positive  success.      It  was  the  same  with 


CONCia'TION   AND   CLASS! I'lCAl  ION  OF    SCKOI' LLOSIS  25 

attenuated  cullunjs  of  i  :4()(j,ooo;  but  because  one  single  animal 
which  had  been  inoculaled  vvilli  a  culturr;  of  i  :2()(),(,<)()  did  nf)( 
become  tuberculous,  must  l his  br  lakcn  ns  ;\  proof  of  1  Ik-  iiinocu<jus- 
ness  of  attenuated  tubercle  toxin  and  at  the  same  lime  tlirtnv  liglit 
on  the  question  of.  the  importance  of  individual  disposition  {vide 
below,  experiments  of  Fraenk(;l  -and  liauniann),  whilst  one  leaves 
out  of  account  the  manifest  possibility  that  bacilli  which  adhere 
closely  cannot  so  readily  disperse,  and  in  I  he  one  case  of  attenuation 
of  I  :2()(),ooo  there  was  perhaps  n(^t  one  living  specimen  present? 
Further,  the  freshness  and  virulence  of  the  culture  seems  ques- 
tionable, so  that  Gebhardt  himself  had  doubts  of  its  virulence; 
besides,  the  time  in  wliicii  the  animals  were  under  observation  (four 
weeks)  was  too  short.  Thus,  at  any  rate,  the  conclusions  drawn 
by  Gebhardt  and  Bollinger  that  virulent  milk  from  tuberculous 
cows  loses  its  virulent  properties  by  a  certain  attenuation  is  com- 
pletely unwarranted,  if  only  based  on  the  ground  of  these  experi- 
ments, and  is  serious  in  its  practical  consequences,  because  the 
tuberculous  mixed  milk  described  by  Bollinger  as  being  to  a 
certain  degree  innocuous  might  possibly  spread  the  danger  of 
belief  among  many  persons.^ 

It  ma}^  be  incidentally  remarked  that  the  expression 
"  dilution  of  milk,"  which  we  so  often  hear,  is  very  unfortunately 
chosen ;  for  only  soluble  or  fluid  matters,  such  as  poison,  can 
be  diluted,  but  a  bacillus  is  not  a  soluble  body.  We  can  just 
as  little  talk  of  a  bacillus  in  dilution  as  we  might  talk  of  a 
crocodile  in  a  certain  dilution  (as  if  it  were  in  a  large  river)  being 
innocuous ! 

Just  as  inexact  is  the  computation  of  Bollinger  and  others 
made  on  the  basis  of  Gebhardt's  experiments,  and  which  we  hear 
so  often  quoted,  that  820  tubercle  bacilli  are  sufficient  to  produce 
infection,  especially  with  the  interpretation  which  is  mostly 
implied  that  about  that  number  are  necessary  to  cause  infection ; 
for,  in  spite  of  the  difficulty  of  dispersal  of  such  adhesive  bacteria, 
such  calculations  are  completely  worthless  when  we  do  not  know 
whether  among  those  820  one,  or  100,  or  800  are  living  or  dead. 
The  same  may  be  said  of  the  experiments  of  Wvssokowitsch. 
Preyss  already  discovered  that  in  inhalation  experiments  40 
tubercle  bacilli  were  more  than  sufficient  to  cause  infection. 
Finde  even  found  20  ample  (how  manv  were  living  he  was  not 
able  to  ascertain),  and  Reichenbach  found  s  >^  s  enough.  C. 
Fraenkel  and  Baumann  could  cause  disease  in  guinea-pigs 
Avith  a  massive  culture  of  i  :  100,000  millions,  and  righth-  supposed 

''■  Thus,  for  example,  Liebe  refers  to  Gebhardt's  experiments,  which 
show  that  milk  even  with  a  dilution  of  i  in  50  loses  its  power  of  infection. 


26  SCROI-'LLOSIS 

thai  with  many  baciUus  cuUures  the  transplanting  of  one  single 
germ  (natmally  a  living  one)  sufficed,  which  coniirms  my  state- 
ment made  in  my  lirsl  issue,  and  which  agrees  with  the  t)pinion 
of  Oehlecker. 

But  if  we  have  no  lowest  limit  under  which  lulx'rcle  bacilli 
are  incapable  of  producing  infection,  still  iIktc  is  no  doubt  that 
the  number  of  bacilli  influences  the  type  and  the  course  of  the 
infection,  as  is  proved  by  numerous  experiments,  many  of  which 
have  been  made  by  myself. 

If  from  the  first  a  large  number  of  bacilli  enter  into  the 
tissues  they  will  be  dispersed  over  a  large  area  through  the  lymph 
channels,  and  will  immediately  form  numerous  foci.  Their  pro- 
pagation is  therefore  more  abundant,  and  the  effect  which  with 
one  bacillus  it  would  have  taken  months  to  attain  is  in  this  case 
obtained  in  weeks.  Thus  it  is  that  inoculation  of  animals  with 
scrofulo-tuberculous  matter  from  glands,  bones,  or  lupus  of  the 
skin  containing  few  bacilli  has  a  much  more  tardy  course  than  an 
inoculation  with  sputum,  cultures,  or  pieces  of  tuberculous  lungs 
containing  many  bacilli.  Besides  which,  in  the  case  of  these  inocu- 
lated particles  of  tissue,  which  are  poor  in  bacilli,  the  bacilli  are 
often  covered  or  encapsuled,  as  one  might  say,  by  layers  contain- 
ing no  germs.  I  will  only  mention  lupus,  in  which  Koch  found  no- 
tubercle  bacilli  till  after  the  43rd  section.  The  bacilli  can  only  come 
into  action  when  this  dead  layer  is  absorbed;  it  is  on  this  account 
that  the  process  is  retarded.  On  dead  soil  these  particles  fail  ta 
grow  unless  they  are  well  rubbed  in.  If  before  inoculation  such 
particles  are  carefully  reduced  in  size,  rubbed  to  powder  and 
flushed  with  some  fluid,  the  bacilli  wdiich  have  been  set  free 
develop  a  much  more  virulent  character,  and  cause,  as  I  have 
been  able  to  prove,  much  more  speedy  and  intensive  tuberculosis 
in  the  same  time  than  if  the  piece  had  been  inoculated  whole. 
This  difference  in  the  nature  and  preparation  of  the  material  for 
inoculation  may  have  contributed  largely  to  the  divergent  results 
obtained  by  different  investigators. 

It  has,  therefore,  been  required  lately  that  when  making  tests 
for  virulence  only  such  particles  of  tissue  shall  be  emploved  as 
have  been  made  uniform  by  culture  (see  p.  33),  Recentlv  a  means 
has  been  found  of  simplifying  these  experiments  in  inoculation 
and  of  placing  them  on  a  surer  basis  by  the  antiformin  method 
(see  p.  247). 

Further,  in  the  material  for  inoculation  from  such  chronic 
processes  as  scrofulosis  and  tuberculosis  which,  intra  corpus,  do 
not  appear  to  have  nearly  that  length  of  life  which  the  imagination 
of  many  authors  has  assigned  to  them,  a  considerable  part  have 


CONCEPTION   ANJJ  CLASSIMCA'JION  OF    SCROI'ULOSIS  27 

died  oil,  and  aL  die  same  lime  as  die  few  living  Ixicilli  are  inoculated 
there  will  be  the  debris  of  decaying  bacteria — toxinswhicii  will 
be  inoculated  in  the  sam(;  place.  This  causes  great  irrilalion  of 
the  tissues.  We  have  in  them  one  of  Nature's  principal  remedies, 
and  reaction  at  once  takes  place,  a  sc^rt  of  healing  process,  or 
encysting,  which  hinders  more  or  less  the  dispersal  and  multi- 
plication of  the  bacilli  inoculat(;d  at  the  same  time. 

The  slower  progress  of  tuberculosis  which  Baumgarten, 
Gosselin,  and  Wesener  obtained  by  inoculating  tubercle  bacilli, 
which  had  been  attenuated  by  iodoform  or  other  chemicals  or 
putrefaction,  may  be  explained  in  tlie  same  way.  It  is  clear  that 
the  greater  part  of  these  must  have  been  dead  or  decayed,  and  .so 
have  anticipated  the  conditions  of  nature  healing.  We  leave  the 
question  of  how  far  the  processes  of  immunity  can  be  imitated  by 
them  out  of  the  question. 

For  all  these  reasons  scrofulous  materials  when  inoculated  into 
other  bodies  may,  now  and  again,  show  a  slower  and  less  active 
effect  than  that  which  has  been  obtained  by  acute  or  even  virulent 
processes.  So,  although  the  statement  has  been  so  often  made  that 
there  is  reduced  virulence  in  the  bacilli  from  scrofulous  foci,  no 
proof  has  ever  been  forthcoming  that  is  entirely  conclusive;  and 
even  the  work  of  Vagades,  who  was  the  first  to  make  tests  to  dis- 
cover the  difference  in  the  virulence  of  tubercle  bacilli,  did  not  com- 
pletely succeed  in  removing  the  doubts  entertained  about  it. 

(b)  Bacilli   of   Human  and   Bovine  Tuberculosis. 

The  question  of  the  virulence  of  the  tubercle  bacilli  in 
scrofulosis  has  appeared  in  quite  a  new  light  since  Koch  (1901) 
demonstrated  that  the  exciting  causative  agent  in  human  tuber- 
culosis and  of  bovine  in  cattle  is  not  identical,  which  had  been 
the  accepted  theory  up  till  then,  but  that  they  represent  different 
types,  if  not  different  species,  which  act  in  a  different  manner  on 
men  than  on  animals,  both  in  their  biological  and  in  their 
pathological  behaviour.  This  gives  us  a  clearer  understanding 
of  the  etiology  of  scrofulosis  and  throws  light  on  many  a  dark 
question ;  but  it  seems  strange  to  us  that  this  point  has  been  so 
little  insisted  on  in  the  recent  literature  on  scrofulosis. 

In  Mllemin's  time  (1865)  human  and  bovine  tuberculosis 
were  considered  different,  and  were  only  identified  after  the  great 
sensation  caused  by  the  discovery  of  the  tubercle  bacillus  and 
the  authoritative  explanation  of  Koch  in  1882.  The  merit  of 
again  drawing  attention  to  certain  differences  in  the  morphologv, 
the  cultural  and  animal  pathologv  of  tubercle  bacilli  of  human 


28  SCROFULOSIS 

or  bovine  origin,  is  due  to  Theobald  Sniiili.  It  was  he  who  set 
the  ball  rolling;  but  who  knows  what  would  have  been  the  fate  of 
the  conmuinication  if  Koch  had  noi  been  induced  lo  test  the 
circunisiances  more  closely  ? 

The  remarkable  circumstance,  that  fur  iweniy  years  after  the 
discoverv  of  the  tubercle  bacillus,  the  human  and  bovine  types 
were  considered  identical  and  were  acknowledged,  or  rather,  re- 
discovered so  late,  in  spile  of  the  discoveries  of  Villemin, 
Langhans,  Orth,  von  Baumgarten,  which  point  to  it,  may  be 
explained  by  the  almost  exclusive  use  of  the  guinea-pig  as  animal 
for  experiment  on  tuberculosis,  not  only  because  these  animals 
are  cheapest  and  easy  to  obtain,  but  also  because  they  react  most 
exactly  and  most  speedily  on  both  types  of  tuberculosis. 

Rabbits  were  less  often  employed,  excepting  for  intraocular 
experiments,  on  account  of  their  susceptibility  to  other  infectious 
diseases,  which  often  had  a  disturbing  effect  on  the  experiments. 
Its  lower  susceptibility  to  human  tuberculosis  had  been  long 
remarked,  and  I  remember  the  time  when  I  was  assistant  at 
Goebersdorf  (1885)  making  many  fruitless  experiments  with  Petri 
to  infect  rabbits  with  sputum,  which  finally  made  us  doubt  both 
our  skill  and  the  accuracy  of  the  information  imparted  by  others, 
and  to  support  the  incipient  scepticism  of  Brehmer  with  regard 
to  tubercle  bacilli. 

The  striking  statements  of  many  authors  who  relied  on  ex- 
periments on  rabbits,  which  statements  contradicted  my  practical 
experience,  can  now  be  satisfactorily  explained.  I  will  only  men- 
tion the  numerous  therapeutic  successes  claimed  by  French 
investigators,  who  were  deceived  because  they  inoculated  rabbits 
with  human  tuberculosis,  to  which  they  are  almost  insusceptible, 
whilst  my  after  tests  (see  Zeitschr.  /.  Hyg.,  vol.  vii)  on  guinea- 
pigs,  which  are  decidedly  tuberculous  animals,  were  one  and  all 
without  result.  A  revisal  of  the  experiments  in  this  direction  is 
advisable. 

One  great  mistake  was  that  they  only  took  into  account  (as 
did  Koch),  when  endeavouring  to  explain  the  individual  dis- 
position of  animals,  the  inconstant  results  obtained  by  inoculating 
rabbits  with  bacteria  of  different  origin,  which  are  always  one- 
sided on  account  of  the  endogenous  factor,  instead  of  studying 
more  closelv  the  exogenous  factor  which  certain  schools,  more 
especially  in  recent  times,  seek,  again  so  one-sidedly,  to  press 
into  the  background,  vestigia  terrent. 

It  is  not  the  place  here  to  discuss  this  much-contested  ques- 
tion more  closely.  Reference  must  be  made  to  the  voluminous 
literature  on  the  subject,  especially  to  the  works  of  Kossel,  Weber 


CONCIil'TION    AND   CLASSIMCATJON  Ol'    SCKOl'l.  LOSIS  2(} 

and  JlcLiss,  TauLc,  'iilzc,  Oclilcckcr,  as  layin^^  lli'-  foundaiirm, 
and  to  the  reports  of  the  English  Commission  lor  Investigating 
Human  and  Animal  Tuberculcxsis,  to  the  debates  of  tiie  Congress 
on  Tu1)erculosis  at  Wasliinglon,  1908,  and  the  works  f>f  I-'ihiger 
and  Jensen,  i.ydia  Kabinc^witsch,  Beitzke,  Eber,  Uurckharrlt, 
&c.,  &c.  The  statements  of  Koch,  as  conclusive  after  tests,  have 
been  confirmed,  that  is  to  say,  wilii  some  modificatirms. 

The  results,  which  are  of  the  highest  impc^rtance,  especially 
for  the  etiology  of  scrofulosis,  may  be  thus  summed  up  :  — 

Tubercle  bacilli  obtained  from  tuberculous  human  or  bovine 
structures  cause  immense  tumours,  from  ilie  size  of  tin;  fist  tfj  that 
of  a  child's  head,  when  subculaneously  injected  into  cattle;  these 
tumours  appear  either  at  the  place  of  inoculation  or  the  nearest 
prescapular  gland  and  the  neck  glands,  and  lead  almost  without 
exception  to  progressive,  and  at  last  to  general  tubercuhjsis,  with 
fatal  ending.  In  apparent  exceptions,  as  in  the  case  of  Kossel, 
where  the  process  was  conhned  to  the  prescapular  gland,  an  intra- 
venous injection  revealed  the  same  complete  and  high  patho- 
genicity as  in  other  cases. 

The  tubercle  bacilli  obtained  from  tuberculosis  in  human 
beings  are  divided  into  two  groups  :  the  one,  which  comprises 
the  great  majority,  when  subcutaneously  injected  into  cattle, 
causes  no  progressive  tuberculosis;  the  animals  continue  to  live, 
unless  they  succumb  to  some  intercurrent  malady. 

Considerable  swellings,  the  size  of  the  palm  of  the  hand, 
appear  at  the  place  of  injection,  which  often  suppurate  and  break 
through  the  skin ;  further  lumps  the  size  of  a  walnut,  a  hen's  or 
a  goose's  egg  are  formed  at  the  nearest  prescapular  gland,  some- 
times beyond  it,  at  the  middle  and  lower  neck  glands ;  in  the  course 
of  time  these  reduce  in  size,  or  even  disappear  completely. 

If  the  animal  be  slaughtered  after  four  to  six  months,  either 
there  are  no  modifications  to  be  discovered,  or,  which  is  most  fre- 
quently the  case,  swelling  filled  with  caseous  or  creamy  pus  at  the 
place  of  injection  is  noticed ;  but  in  many  cases  a  partial  or  even 
considerable  swelling  is  discovered  in  the  nearest  prescapular 
gland  containing  caseous  or  chalky  masses;  and  cvsts  of  connec- 
tive tissue  are  formed  as  a  protection  against  the  environment  (see 
p.  117).  The  longer  the  animal  lives  the  smaller  are  these  pro- 
cesses, and  the  less  often  are  they  found.  We  are  dealing  here 
with  processes  which  remain  localized  on  the  place  of  injection  or 
deposit,  and  with  the  glands  which  lie  nearest ;  and  where  casea- 
tion sets  in  a  spontaneous  retrogression  takes  place  after  a  longer 
or  shorter  period,  or  they  become  covered  with  chalk  or  lime. 
In    a    smaller    group,    the    tubercle    bacilli    obtained    from    man 


^O  SCROFULOSIS 

coincide  exactly  with  the  bovine  bacilli  and  cause  general   pro- 
gressixe  tuberculosis  in  cattle. 

The  counter  test,  the  inoculation  of  bovine  bacilli  in  man,  is 
illustrated  by  some  experiments.  Baumgarten  informs  us  that 
considerable  quantities  of  bovine  bacilli  had  been  subcutaneously 
injected  into  more  than  half  a  dozen  persons  suffering  from  malig- 
nant tumours,  and  there  was  no  resulting  malady  in  consequence, 
with  the  exception  of  small  abscesses.  Spengier  and  Klemperer 
inoculated  bovine  bacilli  into  their  own  bodies  unsuccessfully, 
Small  as  is  the  number  of  these  experiments,  they  go  to  prove  thai, 
as  a  rule,  bovine  bacilli  possess  no  perceptible  virulence,  at  least 
for  adults.  The  different  pathological  behaviour  of  human  and 
bovine  bacilli  corresponds  clearly  to  morphological  and  cultural 
differences,  which  are  emphasized  on  certain  cultural  media 
(serum)  and  on  others  are  lost. 

The  bovine  bacilli  are  shorter,  thicker,  and  more  elongated, 
many  are  wedge-shaped  and  thickened  out  to  a  knob  at  the  end, 
and  more  highly  coloured.  Human  bacilli,  on  the  contrary,  are 
slimmer,  somewhat  curved,  the  ends  of  the  same  thickness,  and 
are  uniformly  coloured;  the  former  are  more  difficult  to- cultivate, 
of  slower  growth,  and  have  a  tender  covering,  which  later  be- 
comes nodular,  wdiilst  the  latter  develop  in  culture  an  eminently 
thick  covering  and  swollen  folds.  These  differences  in  patho- 
genic and  biological  behaviour  undergo  no  rapid  change,  but  are 
stationary  characteristics,  which  remain  in  the  bacteria  in  later 
generations,  whether  they  are  further  propagated  in  culture  or  in 
animals.  It  is  clear,  then,  that  we  have  to  do  with  two  different 
types  :  that  which  is  as  a  rule  found  in  cattle,  the  bovine  type 
(bovine  tubercle  bacillus),  which  for  cattle  is  highly  pathogenic,  but, 
judging  from  its  rare  occurrence  amongst  men,  is  of  less  virulence 
or  avirulent  for  them  ;  and  that  which  principally  occurs  in  man, 
the  human  type  (human  tubercle  bacillus),  which  is  highly  virulent 
for  man,  but  for  cattle  is  less  pathogenic  or  non-pathogenic  and 
causes  no  general  and  progressive  tuberculosis. 

The  method  of  their  differentiation  is  fully  discussed  in  the 
chapter  on  Diagnosis  (p.  266). 

On  account  of  the  importance  of  the  bovine  type  in  the 
genesis  and  course  of  scrofulosis  we  must  examine  the  question 
of  the  results  of  experiments  above  mentioned  a  little  more 
closely. 

It  may  be  presumed  that  ihe  results  brought  forward  are 
established  facts;  where  they  are  contested  it  is  with  reference 
partly  to  unimportant  matters,  or  when  they  are  supported  bv 
single  observations   which  are   subject   to   the   chance   accidents, 


CONCEPTION   AND   ri.ASSIl' ICA'I  ION   Ol'    SCJiOI- ULOSIS  3  I 

•or  by  exj)cfiinen(.s  wliicli  do  noL  coiilorm  lo  ilic  (k-mands  ot 
exact  experiments  which  Koch  so  precisely  (Idincd  ai  \\\<:  Wash- 
ington Congress  (see  |).  2O7;,  and  ih*  rfforc  rannoL  claiin  lo  \)c 
of  value. 

Thus  it  has  been  much  dispulcd  vvlicthfr  die  two  groups 
represent  one  species  or  not.  Arloing,  von  lichring,  I'ibiger 
and  Jensen,  de  Jong,  Goggia,  Maragliano  and  his  school  defend 
the  unilary  idea  by  designaling  die  luoiphological,  cultural,  and 
pathogenic  characters  as  inconstant  and  insufricifnt  for  the 
separation  into  different  species. 

The  question  whether  there  are  two  species  is  only  scientific- 
ally interesting;  in  practice  it  is  quite  secondary.  We  best  avoid 
deciding  it  by  using  the  term  introduced  by  Koch  and  saying 
two  types,  which  binds  to  no  distinctive  characters. 

Differences  in  Virulence. — Some  few  authors  do  not  dispute 
distinct  differences  in  type  in  the  sense  that  bovine  bacilli  repre- 
sent higher  virulence,  but  this  is  contradicted  by  the  simple  fact 
that  the  species  of  bacilli  which  are  highly  virulent  in  cattle  are 
non-virulent  in  man  (von  Baumgarten,  Kiemperer,  Spengler),  or 
exhibit  only  a  trifling  amount  of  virulence,  with  the  exception 
of  a  few  cases  where  the  issue  has  l^een  fatal  (see  p.  39),  and  yet 
when  re-inoculated  in  cattle  develop  their  former  complete  viru- 
lence. 

Koch,  Kossel,  Oehlecker,  Burckhardt,  &c.,  think  that  a 
division  into  two  types  is  justified,  basing  their  theory  on  the 
results  of  exact  experiments.  Others  state,  on  the  contrary,  that  the 
cultural  qualities  peculiar  to  both  types  are  not  always  clearly 
perceptible  and  do  not  ahvays  coincide  with  the  conclusive  patho- 
genic characteristics.  Thus  Lydia  Rabinowitsch  introduces  a 
third  form,  the  atypical  species,  as  an  intermediate  form  between 
the  human  and  the  bovine  type,  wliich  answers  to  what  the 
English  Commission  termed  the  intermediate  group.  Beitzke. 
Theobald  Smith,  &c.,  think  we  cannot  manage  without  such  an 
intermediate  form. 

As  to  cultural  differences,  these  only  appear  clearlv,  as 
Weber,  Oehlecker  and  Koch  have  repeatedlv  and  emphaticallv 
insisted  on,  in  the  above-mentioned  culture  (see  p.  26S),  and  onlv 
then  when  they  are  freshly  taken  from  man  and  animals. 

Even  differences  which  are  hardly  perceptible  in  the  pre- 
paration of  tlie  culture  medium  as  well  as  changes  in  temperature 
modify  the  cultural  characters.  Differentiation  will  also  be 
caused  by  the  choice  of  the  material  subject  to  experiment, 
wdiether  w^e  take  the  quite  fresh,  thin,  peripheral  portion  of  the 
culture  film  or  the  more  central  thicker  part.     This  fact  has  been 


32  SCKOFULOSIS 

emphasized  by  Fibiger  aiul  Jensen.  It  is  possible  to  produce 
from  the  same  strain  culiures  of  completely  different  appearance. 
If  several  infltiences  combine  which  are  unfavourable  to 
differentiation,  the  characteristic  marks  lend  to  disappear.  The 
preliniinarv  conditions  of  culture  to  obtain  an  exact  differentia- 
lion  are  very  delicate,  and  it  may  be  readily  understood  that  if 
they  are  not  sufficiently  observed  it  may  lead  to  the  appearance 
of  atypical  forms. 

These  researches,  made  with  the  object  of  masking  and 
effacing  these  cultural  differences  in  artificial  culture  media  and 
lo  prove  the  relationship  of  the  two  types  (a  thesis  which  no  one 
has  doubted),  in  no  way  comply  with  these  conditions.  It  is 
just  as  if  we  endeavoured  to  study  the  racial  differences  between 
a  white  man  and  a  negro  in  pilch  darkness.  Our  task  should 
rather  be  to  seek  to  make  these  differences  more  discernible 
than  to  do  the  contrary. 

If  we  chose  for  comparison  from  a  series  of  parallel  cultures 
the  finest  grown,  as  we  naturally  should,  we  should  succeed 
without  difficultv  in  introducing  intermediate  forms  between  the 
two  types.  The  special  character  of  these  apparently  atypical 
forms  is  also  questionable  from  the  fact  that  these  deviations  from 
tvpe,  caused  by  unknown  influences,  mostly  disappear  on  further 
culture  (Burckhardt). 

Experiments  in  animals,  too,  will  only  lead  to  a  clear  com- 
prehension of  these  differences  under  certain  sharply  defined  and 
subtle  hypotheses.  For  example,  if  we  subject  an  animal  which 
is  onl}'  slightly  susceptible  to  an  intravenous  injection  Avith  human 
bacilli  a  pathological  appearance  will  ensue  which  will  differ 
but  slightly  from  virulent  bovine  infection. 

Now  an  exactly  uniform  arrangement  of  the  experiment  leads 
to  a  comparison  against  which  there  can  be  no  objection,  for 
besides  the  influence  of  the  type,  unintentional  accessory  circum- 
stances often  exercise  an  influence,  such  as  the  quantity  and  the 
freshness  of  the  culture,  the  fineness  of  the  trituration,  also  the 
age  and  weight  of  the  animal,  the  manner  of  inoculation,  the 
unintentional  piercing  of  a  small  vein  ;  added  to  this,  stocks  of 
the  same  type  exhibit  certain  variations  as  to  the  amount  of 
poisons  contained  and  their  activity;  also  animals  varv  much 
in  their  susceptibility,  especially  rabbits.  If  one  of  these  agents 
which  are  favourable  or  unfavourable  to  infection  be  present  during 
the  experiment,  there  would  naturally  be  deviations  from  the  aver- 
age true  pathological  effect,  even  when  the  same  tvpe  is  employed, 
which  may  lead  even  skilled  investigators  to  false  conclusions 
unless  repeated  experiments  correct  the  error. 


CONCKP'IION    AND   CLASSI  I- K  A  I  ION   OF    SCKOI- LI.OSIS  33 

The  inlrndiiclion  of  idiop.-ii  liic  I  iilxTciiloiis  inf<M:li(>n,  and 
niisi<'ikiii|4  liihcn  iilniis  (  liaii<4c.s  f-u-  die  .sympioms  of  intercurrent 
maladies — as  niisiakinj^^  coccidian  processes  in  rabbits  for  the 
sepliciLMnic  processes  (see  p.  273)— frecjuendy  give  rise  to  faulty 
results,  the  more  easily  the  fewer  the  experiments. 

ll  cannot  be  loo  ot'lcn  insisifd  on  diat  (;.\perimenis  <jn 
animals  can  only  be  considered  as  decisive  after  numerous 
repetitions  and  after  accidental  circumstances  which  might  affect 
them  have  been  carefully  eliminated;  for  the  decision  of  important 
questions  only  such  expcrimenls  can  be  lak'cn  into  account  as  are 
made  in  the  mass,  and  in  wliicli,  from  iImmt  mnnlH-r  and  a  certain 
continuity  in  the  work,  even  in  small  and  comparatively  unimpor- 
tant details,  a  continuity  in  the  material  and  sufficient  personal 
experience  guarantee  correctness.  Therefore  when  such  a  series  of 
investigators  as  Kocli,  Kossel,  Weber,  &c.,  assert  a  constancy  of 
type  in,  form,  culture,  and  pathogenicity,  based  on  a  long  series  of 
experiments,  and  confirmed  by  Jatta  and  Cosco,  Nathan  Raw, 
much  more  weight  attaches  to  the  assertion,  especially  when  they 
are  partly  able  to  discover  the  sources  of  errors  by  mutual 
observation. 

Thus  it  is  not  free  from  objection  to  take  bouillon  containing 
organisms  in  which  the  quantity  of  bacilli  cannot  be  ascertained 
and  with  which  organic  substances  may  be  introduced,  which 
induces  conditions  quite  distinct  from  natural  infection,  instead 
of  taking  a  quantity  of  culture  which  has  been  accurately  selected 
for  its  exact  pathogenic  reaction.  Thus  bouillon  containing 
organisms  is  not  suitable  for  ascertaining  the  variation  of  the 
types,  but  is  more  likely  to  conceal  them. 

Just  as  little  is  it  admissible  to  inundate  the  body  with 
bacilli  by  a  simultaneous  subcutaneous  and  intraperitoneal  injec- 
tion. So  Eber's  experiments  with  bouillon  containing  organisms 
and  his  double  injections  with  the  opposition  based  on  them  to 
a  division  of  types  are  rightly  rejected.  Equallv  right  is  Weber 
when  he  criticizes  Schottelin's  experiments,  where  he  omitted  the 
preliminary  tuberculin  tests  in  the  case  of  cattle,  remarking  that 
even  in  tuberculin  tests,  and  not  taking  into  account  animals  which 
react,  we  mav  count  on  9  per  cent,  of  failures  in  cattle. 

Again,  in  other  experiments  the  accounts  are  frequentlv 
incomplete,  and  so  the  possibility  of  being  entirelv  trustworthv  is 
lost,  or  else  the  experiments  on  cattle,  which  is  a  necessarv 
complement  in  doubtful  cases,  is  wanting,  as  with  Rabinowitsch's 
experiments.  Apparently  non-typical  cases,  on  a  repetition  of  the 
experiment  and  on  further  inoculation,  exhibit  a  completelv  tvpical 
behaviour,  as  the  cases  of  Kossel  and  Burckhardt  prove. 

3 


34  iiCRUKLLOSlS 

Mixed  infeciion  of  hiinian  and  bovine  bacilli,  \vhich  have  otien 
been  studied,  may  al  linies  give  rise  to  sources  of  error  by  causing 
apparentlv  non-t\pical  forms  (Oehlecker,  \\>ber).  If  both  types 
are  combined  in  the  original  material,  both  will  thrive  in  guinea- 
pigs,  whereas  in  rulture  the  l)ovine  type  will  be  suppressevl 
h\-  the  human,  but  when  furllicr  iransplanled  in  a  suitable  species 
of  animal — rabbit  or  cow — the  bovine  bacilli  may,  although  there 
was  no  trace  of  them  in  the  culture,  gain  the  ascendancy  over 
their  non-\  irulent  competitors.  We  know  from  ilu-  experiments 
of  C.  Fraenkel  and  Baumann  that  infective  material,  even  in  the 
proportion  of  1:100,000  millions,  is  capable  of  producing  dis- 
ease. Stocks  of  the  sarne  type  may  show  among  themselves  only 
slight  lluciuations  in  growth  and  virulence  which,  especially 
under  certain  conditions,  brings  them  apparently'  nearer  to  the 
other  tvpe;  evidences  based  on  a  series  of  exact  experiments  and 
free  from  all  objections  which  would  make  the  introduction  of 
an  intermediate  tvpe  needful  are  at  present  lacking. 

Change  of  Type. — Manv  authors,  especially  those  who  oppose 
the  separation  of  the  tvpes,  think  that  both  types  represent  only  one 
varietv  adapted  to  the  species  of  animal  (Dammann  and  ?\Iues- 
semeier,  &c.),  that  thev  may  be  cultivated  one  on  the  other,  and 
that  it  is  also  possible  that  the  changes  can  take  place  in  the 
human  bodv.  The  relative  frequency  of  bovine  tuberculosis 
amongst  children  and  its  rarity  among  adults  was  even  endea- 
voured to  be  explained  by  this  transformation  of  bovine  into 
human  bacilli.  This  question  is  also  of  the  greatest  importance 
on  account  of  the  possibility  of  bovine  scrofulous  infection 
resulting   in   pulmonary   tuberculosis. 

According  to  the  accounts  of  voaBehring.  de  Jong,  Dammann 
and  Muessemeier,  the  \irulence  of  the  human  tvpe  mav  be 
increased  by  passing  through  the  goat.  I  prefer  not  to  enter  more 
closely  into  these  accounts  and  will  refer  to  the  criticisms  on 
them  by  Kossel,  Weber  and  Burckhardt.  I  will  only  remark  that 
in  the  experiments  of  von  Behring,  Roemer  and  Ruppel,  besides 
three  negati\e  successes,  in  one  case  an  increase  of  virulence  was 
apparently  obtained,  but  according  to  the  condition  of  things 
the  cause  of  the  delusion  may  have  ])een  the  introduction  of 
bovine  bacilli  (Kossel). 

In  the  experiments  of  Dammann  and  Muessemeier,  who 
observed  an  increase  of  virulence  after  passing  three  times 
through  rabbits,  and  in  another  experiment  five  times  through 
goats,  the  bovine  bacillus  appears  to  have  been  the  unbidden 
agent  in  producing  spontaneous  infection,  as  the  sudden  increase 
of  virulence  seems  to  intimate,  besides  which  infection  was  partly 


CONCIil'TION    AND   CLASSU'ICA  1  ION   OF    SCKOFLLOSIS  35 

induced   by    organic    malcri.-il,    \vlii(  li    f.\|jcrimcnt.s,    according    lo 
die  above  analysis,  are  noL  conclusive. 

Tlie  J^iglish  C'onmiission  on  'riib<T(  iilosis  is  also  ailc-ged  lo 
have  succeeded  in  oblaining  in(  re.-ised  xirulence  in  ihe  human 
type  in  three  cases  of  passage  through  ihc  body  (^f  the  cow, 
but  only  when  tul^ercuious  organs  were  inoculated,  wliilst  experi- 
ments with  cultures  were  unsuccessful. 

De  Jong  Ijelieved  he  had  enhanced  the  virulence  of  the 
human  type  over  that  of  the  bovine  by  passage  tlirough  the  goal, 
but  no  clear  proof  is  adduced,  because  the  animal  was  used  at 
the  same  time  for  testing  different  kinds  of  tubercuhn  (see  also 
Kossel).  Eber  believed  that  he  had  succeeded  in  bringing  about  a 
sort  of  change;  he,  too,  used  bouillon  besides  subcutaneous  and 
intraperitoneal  inoculation,  a  method  which  has  been  criticized 
above  (see  Kossel,  Weber  and  Burckhardt). 

In  the  case  of  Fibiger  and  Jensen  it  is  just  as  difficult  to 
draw  a  definite  conclusion  as  to  the  change  of  type.  A  dealer 
in  hides  suffered  for  live  to  six  years  from  skin  tuberculosis  in 
the  arm  from  bovine  bacilli.  He  fell  ill  with  pulmonary  tuber- 
culosis; on  post-mortem  examination  the  human  type  was  bred 
from  the  lungs.  But  who  would  call  this  a  metamorphosis  or  even 
think  it  proved  anything  ?  To  the  unprejudiced  observer  what  is 
clearer  than  to  take  for  granted  that  in  this  case  we  have  to  do  with 
one  of  the  many  thousand  infections  of  the  lungs,  quite  indepen- 
dent of  tuberculosis  of  the  skin  ? 

As  we  have  above  mentioned  (p.  34),  in  these  experiments 
spontaneous  and  mixed  infections  give  rise  to  misconstructions. 
As  Burckhardt  has  rightly  remarked,  in  the  cases  which  have 
up  till  now  come  before  us,  either  the  increase  of  virulence  is 
so  trifling  that  it  may  be  placed  in  the  catalogue  of  accidental 
variations,  or  it  is  so  great  and  sudden  that  spontaneous  bovine 
infection  ma}^  be  concluded. 

The  communication  of  Lydia  Rabinowitsch  that  she  has 
isolated  tuberculous  stocks  which  were  similar  in  character  to 
the  human  type  from  milk  is  also  interesting.  Also  the  obser- 
vations of  Dammann  and  Lydia  Rabinowitsch,  according  to 
which,  in  the  case  of  a  slaughterer  who  had  wounded  his 
hand  when  sorting  refuse  meat,  tuberculosis  of  the  bones 
and  in  the  region  of  the  glands  developed  from  the  wound, 
wdiich  culture  proved  to  be  non-typical ;  naturallv  this  is  not  a 
proof  of  variation. 

The  experiments  of  Weber,  Kossel  and  Heuss,  according  to 
which  human  stocks  after  repeated  passage  through  goats  retain 
the    type,    refute    the    theory    of    variation    in    passage    througli 


36  SCROI'LLOSIS 

animals.  Weber's  furiher  expcrimenis  gave  only  negative 
results.     Thus  :  — 

A  huinaii  slock  alter  passiiii,'  5  times  through  stoats  tlurint;'  JS4  days 

S     .,  ..     '         „  .,         516      ,. 

..  ■      ..  ,,4    ,,  ,,  cattle     ,,         580      ,, 

showed  no  perceptible  change  either  in  virulence  or  growth;  the 
same  was  observed  in  a  human  stock  after  remaining  about 
300  days  in  the  body  of  a  pig. 

According  to  \\'eber,  Titze  and  Jorn,  human  bacilli  in  the 
bodies  of  cattle  were  in  three  cases  unchanged  after  a  period  of 
two  years  and  one  month,  and  two  years  and  six  months, 
respecti\ely.  Similar  experiments  by  Gralias  had  also  negative 
results. 

Furiher,  clinical  and  bacterial  observations  refute  the  theory 
of  \ariation.  Hoelzinger  mentions  the  case  of  a  young  man  aged 
24  with  primary  abdominal  tuberculosis  ending  fatally,  the 
origin  of  which  went  back  to  childhood.  On  examination  there 
was  found,  besides  general  tuberculous  peritonitis,  tubercular 
nodules  caused  by  bovine  bacilli,  which,  therefore,  had  not 
changed  in  countless  generations  nor  adapted  themseh-es  to 
their  human  host. 

Oehlecker  cultivated  tubercle  bacilli  with  all  the  characters 
of  the  bovine  type  from  the  tuberculous  metacarpal  bones  of  the 
hand  in  a  boy  aged  8,  the  genesis  of  which,  according  to  the  his- 
tory, must  have  dated  back  six  and  three-quarter  years.  Burck- 
hardt  obtained  bovine  bacilli  from  the  tuberculous  knee-joint  of 
a  girl,  aged  19,  which  had  been  apparently  of  thirteen  vears 
duration.  Koch  informs  us  that  he  has  repeatedly  cultivated 
bovine  bacilli  from  old,  healed,  partly  calcined,  glands  of 
slaughterers  after  many  years.  Hess  also  mentions  two  such 
cases.  Zwick  did  not  succeed  in  changing  tubercle  bacilli  of  the 
avian  type. 

The  fact  that  up  till  now  the  bovine  type  is  found  in  man, 
almost  exclusively  in  places  connected  with  the  organs  of  diges- 
tion, points  to  direct  infection  by  tuberculous  food  and  contradicts 
the  theory  of  change  of  type. 

Taken  altogether,  the  facts  before  us  have  not  even  proved 
the  possibility  of  a  change  of  type,  to  say  nothing  of  proving 
them  in  a  manner  that  is  free  from  all  objections;  and  even  if 
this  possibility  were  proved  by  complex  experiments  in  the 
laboratory  which  are  not  found  in  nature,  it  is  quite  irrelevant 
to  the  practical  side  of  the  question,  to  the  spread  of  human 
tuberculosis,   to  the    transition    of    bovine    scrofulosis    into    pul- 


CONCKI'IfON    AND   Cir^ASSII'lCAIION  Ol"    SCROFULOSIS  57 

monary  ( tibcrciilosis.  ['"or.  as  l\o(  li  |)cii  iiiciii  1\  remarks,  "  in^n 
do  ii()(  fii'sl  lake  llic  Irmihlc  In  inakf  cxpfiimcnls  on  animals  or 
to  prepare  cullures,  bill  cnjos-  lliem  in  lli'-ir  I'resli  anrl  nn<liangefl 
condilion."     See  also  p.    105. 

SIGNIFICANCE  OF  BOVINE   INFECTION. 
THE  OCCURRENCE  OF  THE  BOVINE  TYPE  IN  MAN. 

In  consecjuence  of  tlie  difficullies  eonnecled  willi  llie  exa.:t 
proof  of  the  two  types  (see  chapter  on  Diagnosi.s,  p.  266)  we 
ha\e  a  relatively  small  number  of  experiments  at  our  disposal — 
at  present  hardly  a  hundred  discoveries  of  the  bovine  type  in  man 
— which  naturally  cannot  give  us  even  an  approximate  picture  of 
the  relative  frequency  of  the  two  types   in    man. 

Tn  the  150  cases  examined  by  Kossel,  Weber,  Heuss,  Tilze, 
Tante  and  Oehlecker,  for  the  purpose  of  the  di.scovery  of  the 
human  (H.T.)  and  the  bovine  (B.T.)  type,  tuberculosis  is  thus 
distributed  :  — 

Cases  H.T.     C.-ib<;.s  B.T. 

54'*  adults   had    in    ...         ...         ...         ...         ...         53       ...       — 

Of  these — • 

22  pulmonary  tuberculosis           ...         ...         ...         ...  ...  22  ...  — 

6  primary    intestinal    and    mesenteric    tuberculosis  ...  6  ...  — 

3  tuberculosis  of  the  neck  glands       ...         ...         ...  ...  2  ...  — 

II  tuberculosis  of  the  bones   and  joints       ...         ...  ...  11  ..  — 

And— 

86  children  ...         ...         ...         ...         ...         ...         ...       63       ...       12 

Of  these — 

20  primary    and    mesenteric    tuberculosis 
16  neck  glands  operated  ... 
27  bone    and   joint    tuberculosis    operated 
I   lupus 

Further — 

1  case  of  double  infection  (bovine  and  human  type)  amongst  adults. 

2  cases     ,,  ,,  ,,  ,,  ,,  children. 

*  On  the   other   hand   thirteen    cattle   had  exclusively  bovine    type. 

In  the  last  two  cases  the  bovine  tvpe  was  found  in  the 
mesenteric  glands  and  once  in  the  spleen  ;  in  the  second  case  the 
human  bacilli  were  found  in  the  meninges. 

Taking  the  20  cases  of  primarv  mesenteric  and  intestinal 
tuberculosis  in  children,  of  the  13  cases  due  to  bovine  tuber- 
culosis 4  were  fatal   (no  fewer  than   one-third).     Of  the  7  cases 


7 

13 

10 

6 

26       .. 

I 

I 

— 

38 


SCROFULOSIS 


of    liiuiian    tuberculosis   3    were    fatal  ;    the    rest    were    secondary 
discoveries. 

The   tliird    report    t)f  the    l-ini^lish   Commission    inchitles    loS 
cases  of  human  tuberculosis,  which  are  distributed  thus  :  — 


Cast*. 

14  of  pulmonary  tuberculosis 

28  of  tuberculous  sputum  ... 

3  of  miliary   tuberculosis 

3  of  tuberculous   meningitis 

5  of  tuberculosis   of   the   bronchial   glands 

Q  of  tuberculosis  of  the  cervical  glands 

2Q  of  primary  abdominal  tuberculosis  ... 

14  of  tuberculosis    of    bones    and    joints 

3  of  urogenital   tuberculosis 


108 


Times  H.T. 

14 

26         . 

Times 
'limes  B.T.             mixed 
H.T.  &  B.T 

2 

. 

3         • 

3 
3 

■ 

. 

— 

2 

■6       . 

3 

. 

13 

14 

2 

13 

• 

1 

3 

— 

. .    •■- 

84 


19 


Burckhardt  had  5  cases  of  b(^\ine  tuberculosis  amongst 
49  cases  (10  per  cent.)  of  surgical  tuberculosis  which  were  not 
specially  selected,  and  incltided  tuberculosis  of  bones,  joints  and 
neck  glands.  Retzke  found  human  tuberculosis  twenty-two  times 
and  once  an  atypical  form  in  25  cases  of  children  who  had  died  of 
tuberculosis.  Amongst  children  Spronk  found  that  20  per  cent, 
were  suffering  froin  bovine  tuberculosis. 

Smith,  Ra\enal,  de  Schweinitz,  Dorset  and  Schroeder, 
Fibiger  and  Jensen,  Westenhoefer,  Eber,  Fife  and  Ravenal, 
Rabinowitsch,  Duval,  Mohler,  Parodi,  Karliski,  &c.,  have 
communicated  other  cases. 

General  conclusions  cannot  be  drawn  from  these  cases, 
because  these  researches  were  inade  for  the  special  purpose  of 
watching  the  bovine  bacilli.  But  we  may  conclude  with  certainty 
from  them  that  bovine  infection  occurs  only  rarelv  in  adults 
and  principallv  in  childhood,  and  apparentlv  the  younger  the 
child  the  oftener  it  is  found. 

In  the  cases  of  Kossel,  ^^"eber  and  Ileuss,  Oehlecker  and 
Burckhardt,  amongst  57  cases  above  the  age  of  15  no  case  of 
bovine  affection  was  found,  w'hilst  among  71  cases  of  children 
under  15  years  13  such  cases  w^ere  noted. 

Counting  the  primary  abdominal  cases  of  A\^eber,  of  the 
English  Coinmission  and  14  cases  quoted  by  Weber  of  56 
children  suffering  from  bovine  tuberculosis,  20  occurred  before 
the  6th  year,  2  between  the  6th  and  loth  vears,  4  between  the 
loth  and  15th  years. 

The  bovine  type  occurs  also  in  infancv,  as  a  case  of  Fibiger 
and  Jensen  shows,  but  apparentlv  only  exceptionally. 


CONCIil'TlON   AN'I)  CI.ASSII- K  Al  ION  OV   SCROFULOSIS  39 

BOVINE  TYPE  IN  ADULTS. 

M'lial  bovine^  infcclimi  very  rarely  orciirs  in  iIm'  ini'-nial 
orp-ans  of  adiills  iiiav  Ix'  acccnicd  as  an  f'stablisli<-d  lad.  If  \\<t 
cxct'pl  (he  Cases  in  wliicli  llu;  mixed  types  have  appeared, 
Dammann  and  Miissemeier  have  found  the  bovine  type  in  the 
case  of  a  young  man  aged  25  suffering  fn^in  peritonitis,  whicli  ran 
a  favourable  course,  and  Hoelzinger  in  a  fatal  case  of  primary 
abdominal  tuberculosis  in  a  young  man  aged  24,  bui  in  Ijoili  cases 
it  is  questionable  whether  the  infection,  as  su(  h,  did  not  go  back 
lo  the  time  of  their  youth.  L.  Rabinowitsi  h  has  cultivated 
bacilli  from  the  calcined  mesenteric  gland  of  a  woman,  aged  30, 
who  died  of  another  disease.  Weber's  researches  prove  the 
possibility  of  infection  in  later  years  ;  according  to  him,  a  woman 
who  had  drunk  raw  milk  for  two  years  from  a  tuberculous  cov/ 
developed  a  tuberculous  ulceration  of  the  muc(nis  membrane  of 
the  cheek  which  was  of  bovine  character. 

Hoelzinger's  case  proves  that  bovine  infection  can  lead  to 
fatal  results  even  in  adults,  whilst  that  of  Fibiger  and  Jensen  is 
not  conclusive  (see  p.  35),  for  it  is  obvious  that  pulmonary  tuber- 
culosis is  independent  of  the  bovine  infection  ;  the  older  cases 
of  L.  Pfeiffer,  Ravenal  and  Hartzell  are  not  free  from  objection 
in  this  respect. 

Older  observation  of  skin  tuberculosis  after  injury  or  after 
handling  bovine  tuberculous  matter  point  to  bovine  infection  of 
the  skin  in  adults,  as  in  the  cases  of  Tscherning,  Jadassohn, 
Braquehaye,  Johne,  Jong,  Mueller,  Leloir,  Grothan,  Troje,  &c. 
(see  G.  Cornet,  "  Die  Tuberculose,"  second  edition,  pp.  74-75). 

The  bovine  bacillus  was  proved  in  such  cases  by  von  Spronk 
and  Hofnagel  by  its  virulence  in  calves,  in  tuberculosis  of  the  skin, 
and  glands  caused  bv  a  wound  when  dissecting  a  tuberculous 
cow,  and  again  by  Kleine  by  cultures  in  the  case  of  five 
slaughterers  suffering  from  tuberculosis  verrucosa  cutis  (see 
chapter  on  Infection,  p.  76). 

Here  the  disease  was  confined  to  the  place  of  inoculation 
and  the  nearest  gland.  Niche's  case  must  also  be  mentioned — 
the  infection  of  a  dairyman  through  an  injurv  caused  by  abscesses 
in  the  armpit  of  the  bovine  type. 

BOVINE  TYPE  IN  PULMONARY  TUBERCULOSIS. 

The  fact  that  the  bovine  type  is  hardly  ever  found  in  tuber- 
culosis of  the  lungs  is  of  the  greatest  importance.  Arloing 
professes  to  have  found  it  several  times  in  a  cavitv.  Eber 
mentions  bovine  bacilli  which  he  proved  by  inoculation  to  exist 
in  the  lung  substance;   but  this  experiment  of   Eber  cannot  be 


40  SCROFULOSIS 

taken  inio  consideration  (MI  the  abovc-nu-niioned  grounds  (see 
p.  33).  A  second  case  in  whii-h  lie  inoculaied  ihe  iM-ain  tubercle 
of  a  person  sufTering  from  phthisis  naturally  prini-s  nothing  as 
to  the  lungs  (Weber). 

De  Jong,  and  Stuurmann  cultivated  the  bovine  type  from  the 
sputum  of  a  country  girl,  aged  27,  who  was  constantly  occupied 
with  tuberculous  cattle.  Mohler  and  Washburn  together  describe 
a  similar  case,  and  the  English  Commission  on  Tuberculosis 
cultivated  the  bovine  bacilli  from  the  l)ronchial  glands  of  a  cow 
which  had  been  fed  wnth  tuberculous  sputum.  In  these  cases, 
however,  it  is  not  impossible  that  the  bovine  bacillus  was  intro- 
duced into  the  sputum  by  means  of  butter  or  milk  beforehand, 
and  in  the  latter  case  independent  spontaneous  infection  may  also 
be  suspected.  Beitzke's  discovery  of  bo\ine  bacilli  in  the  caseous 
bronchial  gland  of  a  phthisical  child  is  of  more  importance,  but 
it  is  not  fullv  proved  that  the  tuberculosis  of  the  lung  was  induced 
bv  the  bovine  tvpe  or  whether  it  was  only  an  accompaniment  of 
the  human  tvpe.  In  the  one  case  of  i\Iietzsch  the  sputum  of  a 
person  suffering  from  phthisis  was  highly  virulent  in  a  rabbit, 
but  a  calf  remained  free  from  tuberculosis;  again  a  ]M-()of  of  how 
necessary  experiments  on  cattle  are  in  arbitrary  or  questionable 
cases. 

The  discoverv  of  the  bovine  type  in  miliary  tuberculosis  of 
the  lungs  and  general  tuberculosis  of  the  bronchial  glands  proves 
nothing  as  to  the  part  it  plays  in  the  etiology  of  progressive 
pulmonarN'  tuberculosis.  C.  Spengler's  statement  that  the  bo\-ine 
type  is  symbiotic  with  the  human  bacillus  in  most  cases  of 
phthisis  has  not  been  confirmed  either  by  the  after-tests  of 
G.  Schroeder  or  from  any  other  quarter.  ^lueller  found  human 
bacilli  in  the  sputum  of  51  persons  suffering  from  phthisis;  so, 
according  to  his  account,  632  cases  of  human  bacilli  culti\ated 
from  sputum  are  known. 

At  present  completely  reliable  cases  of  the  genesis  of  tuber- 
culosis of  the  lungs  caused  by  the  bovine  type  are  not  known, 
therefore  the  bovine  type  (and  with  il  infection  through  millc) 
plays  only  a  secondary  part  in  human  tuberculosis,  as  it  is  onlv 
phthisis  which  lends  to  tuberculosis  its  dangerous  social  and 
economical  character  and  causes  eleven-twelfths  of  the  deaths. 

It  is  interesting  in  this  instance  to  remember  the  calculations 
of  Speck  against  von  Rehring,  according  to  which  of  8,010  persons 
suffering  from  phthisis,  73  per  cent,  were  infants  nourished  bv 
mother's  milk  and  not  cow's  milk ;  according  to  Sabotta's  account, 
more  than  176  persons,  i(S'4  per  cent,  of  children  at  the  breast, 
35" I   per  cent,  of  those  which  had  mixed  food,  and  41  per  cent. 


CONCIil'TION   AND   CI-ASSIFICAI  ION   OF    SrKOI' I  I.OSIS  4I 

of  lliose  aiiidcially   noiirislifd,    \\<ic  1  iiIxtcuUmis  ;  a  conlradiction 
which  may  he  pul  down  lo  S.-ihoiK-i's  loo  small  niimbfi*  of  cases. 

BOVINE  TYPE  IN  MESENTERIC  AND  CERVICAL 
TUBERCULOSIS. 

Il  ni.'i\'  I)c  clcarlv  galhcrcd  I'lom  \\\<-  ii),'iicii;il  hffor*'  iis  thai 
l)oviiU'  bacilli  arc  prcscnl  ahnost  uilhoul  cxccjjijon  in  youth, 
especially  in  chihlhood,  dial  die  bovine  infection  attacks  as  a 
rule  in  die  lirsl  place  die  ehgeslive  cjmal  and  the  organs  c(jn- 
nected  with  il,  (■.si)C(  iail}-  the  mesenteric  and  neck  glands.  It  is 
clear  from  ihis  dial  die  l)o\inc  bacilli  cnicr  iIh-  body  bv  swal- 
lowing;; thus  the  source  of  the  infection  is  clearly  indicated, 
namely,  milk  and  milk  products  derived  from  tuberculous  cows, 
which,  especially  in  the  case  of  young  children,  are  the  chief 
articles  of  diet. 

On  the  other  hand,  scrofulosis  is  almost  entirely  a  cldld's 
disease;  tuberculous  mesenteric  and  neck  glands  are  its  chief 
pathological  symptoms,  therefore  there  can  be  no  C|uestion  of 
the  frequently  close  relationship  between  bovine  infection  and 
scrofulosis;  the  supposition,  wdiich  has  often  been  expressed,  that 
scrofulous  infection  is  for  the  most  part  to  be  put  down  to  the 
consumption  of  tuberculous  milk,  is  thus  completely  confirmed. 

Among  the  small  number  of  examinations  hitherto  made  there 
were  in  Weber's  20  cases  of  primary  mesenteric  and  intestinal 
tuberculosis  amongst  children,  13  caused  by  the  bovine  tvpe ; 
in  the  29  cases  of  abdominal  tuberculosis  in  childhood,  of  the 
English  Commission,  14  \\ere  bovine;  so  in  49  cases,  27  (i.e., 
more  than  the  half)  were  caused  by  the  bovine  bacillus,  besides 
which,  in  4  cases — a  relatively  large  number — there  was  mixed 
infection  (bovine  and  human)  present. 

Further,  Oehlecker  found  that  in  28  neck  glands  which  had 
been  operatively  removed,  14  belonged  to  pvogenous  scrofulosis 
and  14  were  tuberculous;  of  this  number  12  were  amongst 
children,  and  of  these  i2'4  (i.e..  one-third)  were  tuberculous  cases 
in  which  the  tubercle  bacillus  was  the  creating  agent  of  the  disease. 
These  4  cases  occurred  between  the  ages  of  ij  and  5  vears. 
Altogether  amongst  16  cases  of  tuberculosis  of  the  neck  glands, 
operated  by  Weber  and  his  colleagues,  6  were  of  bovine  tvpe, 
10  were  of  human  type,  and  2  (in  adults)  were  of  human  type. 

Amongst  the  9  cases  of  tuberculosis  of  the  cervical  glands 
examined  by  the  English  Commission  3  were  of  bovine  character ; 
in  9  cases  communicated  by  Goodale  with  tuberculosis  of  the 
tonsils,  neck  glands  and  adenoid  growths  between  the  ages  of 
2  and  6  years,   the  operative  matter  of  which  was  examined  bv 


42  SCROFLLOSIS 

Smith,  in  4  lases  ihe  bo\  ine  bacillus  was  culiixaied;  ot  Biirck- 
hardt's  9  cases  oi  tuijcrculosis  of  ihe  neck  glands,  only  one 
exhibited  the  bovine  type,  8  the  human  type.  These  remarkably 
small  results  in  comparison  with  those  of  other  authors  may  be 
explained  bv  the  greater  age  of  the  cases,  for  in  Burckhardt's 
g  cases,  7  were  already  over  15  to  28  years,  and  the  only  case 
whicii  was  under  10  years  was  the  bovine  case  in  a  child  of 
3  years. 

Xaturallv  these  figures  do  not  give  us  a  proper  impression 
of  the  importance  of  bovine  infection  in  mesenteric  tuberculosis 
t)f  the  glands,  for  hitherto  the  examinations  have  been  made 
principally  on  specially  chosen  cases.  Most  of  the  cases  dealt  with 
have  been  fatal  and  advanced  processes  of  abdominal  tuberculosis, 
and  seldom  accidental  discoveries  in  the  case  of  death  front  other 
causes,  so  that  a  great  number  of  cases  of  pure  tuberculosis  of 
the  mesenteric  glands,  abdominal  scrofulosis,  which  sekU)m 
cause  death,  swellings  with  small  caseating  foci,  which  anatomists 
themselves  pass  over  without  remarking,  or  even  do  not  see 
because  they  heal  spontaneously,  await  closer  investigation,  it 
is  hardly  doubtful  that  it  is  just  amongst  these  that  the  bovine 
bacillus  will  be  most  frequently  discovered  to  be  the  cause. 

Also  the  tubercles  of  the  neck  glands  which  have  hitherto 
been  examined  have  been  mostly  derived  from  severe  cases  which 
burst  spontaneously  and  challenged  operation  ;  the  larger  field 
of  chronic  tuberculous  swelling  of  the  neck  glands  extending  over 
a  long  period  without  any  considerable  changes,  and  which 
disappear  at  last  clinically,  have  been  almost  entfrely  passed  over. 
One  may  take  for  granted  that  these  two  are  probably  caused 
in  the  first  place  by  the  bovine  bacillus. 

The  examination  of  tuberculosis  of  the  bones  and  joints  in 
children,  which  we  are  accustomed  to  consider  as  scrofulous,  had 
results  which  w^ere  remarkable  in  many  ways. 

In  25  cases  of  tuberculosis  of  the  bones  and  joints  in  children 
under  15,  Oehlecker  only  once  found  the  bovine  type  and  twenty- 
four  times  the  human  type. 

In  19  cases  of  bone  and  joint  tuberculosis  in  children,  Burck- 
hardt  found  the  bovine  type  only  twice  and  the  human  type 
seventeen  times. 

The  ages  of  the  three  bovine  cases  were  8,  11  and  14  years, 
respectively. 

In  II  persons  over  15  Oehlecker  found  the  human  type  only 
twice;  in  10  cases,  Burckhardt  found  one  of  bovine  type  in  a 
person  aged  19;  with  this  exception  all  were  of  human  tvpe. 

The  English   Commission  noted    14  cases  of  tuberculosis  of 


CONCEPTION    AND   CLASSIITCAJTON  OF    SCROI- ULOSIS  43 

bones  and  joints;  in  one  ease  there  was  niix^d  infection,  i.e., 
tubercle  bacillus  and  pyoj^enic  or,f,^'inisms,  iIm-  oilier  13  were  r)f 
human  type. 

We  must  lake  iliis  o))puiiiinii  v  of  r'-(  .-illing  the  fad  that 
Krompecher  and  Zimnicrni.'inn  ( onsid*  red  ii  ;i  niislake  to  attribute 
the  chronic  and  more  favoiir.'iblc  foiin  of  1  iibcrculosis  of  the  bone 
and  joint  to  die  lesser  \inilrn(c  t>\  die  bacillus;  but  Gruner, 
on  the  other  hand,  found  sponiam-ous  re.-icijon  in  tuberculosis 
of  the  bone  similar  to  that  found  in  s(  rofnlosis,  duTcfore  lii_L,di''r 
than  that  of  tuberculosis. 

The  English  Commission  gixcs  ol)ser\ations  on  20  eases 
of  lupus;  in  8  cases  the  tubercle  bacilli  culiivated  from  it  had  the 
cultural  signs  of  bovine  tuberculosis,  Inii  in  the  case  of  calves 
and  rabbits  they  proved  themselves  in  part  less  virulent.  Besides 
these,  isolated  cases  of  Weber,  Burckhardt  (one  case  of  17  years) 
were  of  human  type. 

Rosenberg,  who  observed  that  primary  nasal  and  pharyngeal 
lupus  was  often  found  amongst  women  and  girls  in  the  country, 
raises  the  question  whetlier  the  bovine  type  does  not  come  into 
play  here. 

The  importance  of  bovine  infection  for  tuberculosis  in  man 
is  therefore  in  general  very  inconsiderable ;  on  the  contrary,  in 
tuberculosis  of  children,  especially  in  tuberculosis  of  the  mesenteric 
and  neck  glands,  it  plavs  an  Important  part.  Amongst  the  cases 
mostly  regarded  as  scrofulous,  according  to  observations  hitherto 
made,  it  is  the  cause  of  more  than  a  third  of  all  the  most  severe 
cases,  in  an  examination  of  the  lighter  ones  the  proportion  in 
favour  of  bovine  infection  would  be  considerably  increased. 
There  is  no  basis  for  Abramowski's  distinction,  according  to 
which  torpid  scrofulosis  is  of  bovine,  but  irritant  scrofulosis  of 
human  nature. 

A  complete  separation,  such  as  Caw  and  Raw  tried,  by 
stating  that  tuberculosis  caused  by  inhalation  was  of  human 
origin — that  intestinal  tuberculosis,  tuberculous  peritonitis,  tuber- 
culosis of  the  bone  and  joints,  lupus,  miliary  tuberculosis,  uro- 
genital tuberculosis,  and  tuberculosis  of  the  middle-ear,  were 
caused  by  the  bovine  type — is  contrary  to  the  fact  that  in  intes- 
tinal, and  especially  bone  tuberculosis,  human  iDacilli  are  fre- 
quently foimd.  By  the  demonstration  that  bovine  bacilli  are 
frequently  the  cause  of  scrofulous  tuberculosis,  the  knowledge  of 
this  disease  has  been  much  advanced,  and  manv  striking  svm- 
ptoms  are  explained  bv  it. 

Thus  it  is  a  well-known  fact  that  scrofulosis  appears,  as  a 
rule,    towards   the   end   of    the    first    and    second    vears.     Bovine 


44  SCROFULOSIS 

iiifeciic)!!  appears  alnictsi  wiiluiu:  cxccpiion  afler  the  first  }ear ; 
primary  tuberculosis  of  ihe  mesenteric  glands  wiih  the  bovine 
characteristics  is  rare  in  infancy.  Fibiger  and  Jensen  have 
described  two  such  cases  (ii.  12)  in  which  the  consumption  of 
milk  from  a  partly  tuberculous  cdw  was  proved. 

As  Eden's  and  others  have  remarked,  the  reason  of  this  lies 
clearlv  in  the  fact  that  in  infancy,  even  amongst  the  poorer  classes, 
the  milk  is  generally  boiled,  whilst  in  later  years,  besides  fre- 
quenilv  consuming  milk  in  ihe  raw  slate,  butter  and  other  milk 
products  increase  Ihe  opponuniiics  for  infection.  Contradiitions 
which  have  hitherto  been  found  in  treatises  on  scrofulosis  ami 
tuberculosis  now  find  a  satisfactory  explanation. 

The  relation  of  scrofulosis  to  tuberculosis,  including  consump- 
tion, has  been  described  in  many  ways  in  the  course  of  time.  For 
centuries  it  was  a  clinical  axiom  that  scrofulosis  predisposed  to 
tuberculosis.  Former  clinical  experience  had  taught  that  most  of 
those  who  suffered  from  scrofulosis  died  later  of  tuberculosis  of 
the  lungs,  and  found  in  this  fact  support  for  the  etiological  identify 
of  the  tw^o  diseases. 

According  to  a  recent  statement,  which  is  as  yet  unproved, 
those  who  are  predisposed  to  scrofulosis  possess  a  certain  amount 
of  protection  against  tuberculosis  on  account  of  their  violent  re- 
action to  unaccustomed  irritation,  which,  according  to  INIoro,  is 
an  act  of  self-preservation,  and  the  mild  course  of  scrofulous 
tuberculosis  is  owing  to  this.  But  they  forget  in  this  instance 
that  morbid  over  reaction  has  not  the  same  effect  as  the  reaction 
of  healthv  tissue,  just  as  little  as  the  flabby  granulations  of  the 
weak,  in  tlie  healing  of  a  wound,  have  not  the  same  efifect  as  robust 
granulation. 

Tn  strict  antithesis  to  this,  Czerny  states  that  just  by  com- 
bating this  exudative  agent  he  has  changed  such  weaklings  "  into 
blooming  children  with  tuberculosis."  One  sees  how  easv  it  is 
for  (^linical  experience  to  be  iniluenced  bv  preconceived  subjecti\-e 
opinions,  which  give  rise  to  false  conclusions  unless  based  on 
temperate  figures. 

When  speaking  of  the  ttiberculosis  of  childhood,  Kar  €to')(i)v 
(human  infection),  its  great  danger  is  unixersallv  emphasized.  In 
the  period  of  infancy  it  is  considered  to  be,  almost  without  excep- 
tion, fatal  ;  but  also  in  later  years  it  has  a  decided  tendencv  to 
spread  and  attack  other  organs,  as  the  experience  of  all  patho- 
logists and  phvsicians  for  children's  diseases  concur  in  proving. 

On  the  contrarv,  in  all  treatises  on  scrofulosis,  which  is  even 
attempted  to  be  merged  into  tuberculosis,  it  is  especiallv  noted  how 
favourable  is  the  course  it  takes  in   the  Inro-pst    number  of  cases, 


CONCKI'TION   AND  CLASSIMCATION  OF   SCROFULOSIS  45 

that  no  one  dies  of  scrufulo.si.s,  also  oilif-r  remarks  \vlii(  li  hardly 
agree  with  ihe  above  sad  pictures. 

Escherich  calls  the  jmhc  scrolnlosis  caused  by  tuberculo-loxic 
changes  in  the  inlegunienls  the  most  harmless  of  infantile  tuber- 
culosis, which  even  offers  a  sort  of  protection  against  later  tuber- 
culous infection;  and  also  scrofulous  tiibfrciilosis  occurring  with 
manifest  foci  appears  1<j  Jischerich  io  lake  a  more  favourable 
course  than  the  tuberculous  form  which  is  tuberculous  from  the 
beginning. 

The  numerical  occurrence  of  tuberculosis  ol  the  neck  and 
mesenteric  glands  points  to  the  fact  that  other  sources  of  infection 
besides  the  usual  ones  collaborate  at  least  in  a  ccjnsiderable  degree  ; 
besides  which,  the  mild  course  of  the  infections,  just  at  an  age 
when  tuberculosis  proves  itself  so  harmful,  shows  that  these  other 
sources  of  infection  are  different  in  their  characteristics  from  the 
usual  tuberculous  virus. 

There  can  be  no  cjuestion  about  referring  all  tuberculo- 
scrofulous  affections,  especially  affections  of  the  glands,  to  bovine 
infection.  But  if  a  part  of  scrofulosis  depends  (as  I  take  it,  it 
does)  on  pyogenic  infection,  and  so  has  nothing  to  do  with  tuber- 
culosis (as  in  Oehlecker's  eighteen  cases  it  had  not) ;  if,  as  it  seems, 
a  further  considerable  portion  of  the  remaining  scrofulo-tubercu- 
lous  cases  were  not  caused  by  true  human  bacilli  but  by  the  bovine 
type  (as  bacteriological  differential  diagnosis  has  already  proved 
to  be  the  case),  then  it  is  plain  that  the  gloomy  colours  in  which 
we  are  wont  to  paint  the  tuberculosis  of  childhood  are  here  con- 
siderably brightened,  for  the  bovine  type  is  without  exception  less 
pathological  for  the  child  than  human  bacilli. 

It  is  true  the  bovine  infection  can  cause  in  many  cases,  and 
especially  in  very  young  children  (exceptionallv  in  adults),  pro- 
gressive tuberculosis  or  general  miliary  tuberculosis,  a  tubercu- 
losis which  cannot  be  distinguished  by  its  proportions  and  changes 
from  virulent  infection  of  the  human  type  in  persons  of  the  same 
age. 

It  is  much  more  frequent  for  the  bovine  infection  to  act  at 
the  point  of  entry  or  in  the  nearest  gland,  as  is  the  case  with  the 
human  bacilli  when  inoculated  in  the  calf,  and  to  give  rise  to  foci 
which  remain  localized.  After  some  months,  and  perhaps 
dragging  on  for  many  years,  swellings  of  various  sizes  ensue  with 
caseation  and  suppuration  often  complicated  bv  mixed  infection, 
but  showing  unmistakable  tendency  to  heal,  and  healing 
eventually.  The  bovine  type,  especially  w^hen  introduced  in  small 
quantities,  appears  to  be  much  more  mild  and  almost,  if  not 
entirelv,  non-virulent. 


46  SCROI-LLOSIS 

Wc  nuisi  noi  judge  of  the  course  from  the  material  we  have 
liitherio  obtained;  for  those  cases  which  were  cht)sen  for  examina- 
tion were,  as  has  been  stated  above,  niosily  fatal,  and  but  seldom 
accidental  discoveries.  All  those  numerous  small  neck  and 
mesenteric  glands  showing  little  changes,  Inu  which  may  here 
and  there  cause  clinical  symptoms  which  retrograde  and  are  for 
the  most  part  attributed  to  the  bovine  type,  have  been  little 
examined.  In  spite  of  the  immense  amount  of  work  already 
done  we  are  only  at  the  beginning  of  these  researches,  and  must, 
therefore,  take  care  not  to  draw  too  far-reaching  conclusions  from 
the  small  amount  of  material  at  present  to  hand. 

A  further  contradiction  of  the  experience  hitherto  obtained  is 
explained  bv  the  recognition  of  bovine  infection  as  one  of  the 
causes  of  scrofulosis. 

I  have  before  drawn  attention  to  the  fact  ("  Tuberculose," 
second  edition,  p.  401)  that  aniong  clinically  tuberculous  children 
the  source  of  infection  may  and  must  be  found  as  a  rule  in  their 
nearest  surroundings,  in  parents,  sisters  ("  pseudo  heredity  "),  or 
in  servants;  for  the  important  part  played  by  infection  from  com- 
rades later  cannot  then  have  come  into  force. 

Among  scrofulous  children  this  source  of  infection  is,  as  a 
rule,  absent.  As  has  been  remarked,  such  children  are  born  in 
manv  cases  of  non-tuberculous  parents.  Heredity  (pseudo- 
hereditv)  here  plavs  a  very  minor  part,  naturally,  for  the  infection 
arises  in  many  cases  from  bovine  bacilli  in  butter  and  milk. 

Amongst  children  reacting  to  the  cutaneous  test — the 
cutaneous  reaction  being  of  special  importance  when  dealing  with 
the  class  of  tubercle  bacilli — Hillenburg  found  tuberculosis  in  the 
familv  in  15  per  cent.,  so  that  in  85  per  cent,  the  source  of  infec- 
tion for  the  reaction  probably  lay  elsewhere.  Rightly  interpreted, 
does  not  this  speak  volumes?  especially  when  one  finds  further 
that  in  120  families  whose  children  reacted  positively,  in  twenty- 
two  families  the  relations  showed  no  reaction.  Mendelsohn  also 
found  in  twenty-five  cases  of  primary  intestinal  tuberculosis  that 
in  eighteen  there  was  no  tuberculosis  in  the  family. 

In  recent  researches  this  difference  is  thrown  into  bolder  relief. 
Weber  calls  special  attention  to  the  fact  that  amongst  children  with 
human  tuberculosis  the  opportunity  for  human  infection  could, 
as  a  rule,  be  established.  Out  of  nine  cases,  in  eight  either 
the  parents  or  the  relations  were  tuberculous,  but  in  thirteen 
bovine  cases  twelve  of  the  parents  and  relations  were  free  from 
tuberculosis;  one  case  was  undecided.  It  was  the  same  in  the 
other  cases  reported  by  nine  other  authors. 

It  is,  naturally,  only  the  history  of  children  who  have  little 


CONCEl'TION    AND   C;LAS.SI  FICA'IION  OK    SCIU)!  r  I.OSIS  47 

intercourse  willi  llic  oiilsidc  world  whic  li  (;iii  ,l;i\'-  us  a  siii<; 
indication  of  die  ci  iolo^ic-d  diUci-cni  i;ii  mn  nt  i\p'-.  On  account 
of  IIh'  rclalivc  frc(|iicn(\'  of  double  infcilion,  Imrnan  \y\x-  and 
l)ovin('  lypc,    I  do  noi  allridi  loo  nni*  ii   iiiipori.-mrc  lo  it. 

B,— THE  ENDOGENOUS  FACTOR     PREDISPOSI- 
TION   TO   SCROFULOSIS. 

GENERAL    DIATHESIS. 

Historical. 

Tile  genesis  of  this  peculiar  complexus  of  diseases  is  not 
SufBciently  accounted  for  only  b\'  the  intrusion  bacilli.  I'or  no 
age  is  entirely  free  from  contact  witli  tubercle  bacilli  and  pus 
cocci,  as  is  proved  by  tiie  frequency  of  pure  tuberculous  and 
suppurative  processes  at  all  ages.  Scrofulosis,  on  the  contrary, 
appears  almost  without  exception  in  the  years  of  growth,  and 
almost  never  later,  even  when  the  individual  is  exposed  to  the 
same  outward  conditions. 

It  is  clear,  then,  that  the  preliminary  condition  must  lie  in 
man  himself,  and  in  a  condition  of  the  whole  body  or  certain 
parts  of  it  peculiar  to  youth,  which  in  later  years  disappears  of 
itself. 

The  nature  of  this  peculiar  condition  of  body  which  induces 
a  predisposition  to  scrofulosis  lias  been  at  different  times  variously 
explained  according  to  the  notions  of  physical  science  which 
governed  the  spirit  of  the  age. 

In  the  first  place  the  whole  body  was  included  in  the  pre- 
disposition to  scrofulosis,  an  opinion  which  tinds  certain  support 
in  the  dispersal  of  scrofulosis  over  the  most  various  organs. 

In  the  time  of  humoral  pathology  one  would  naturally  seek 
the  causes  in  the  humours  themselves  by  supposing  an  acrid 
substance  to  be  circulating  with  them.  This  "acrimonia."  or 
"  dyscrasia  acris,"  is,  according  to  Hufeland,  a  specifically 
changed  or  corrupted  Ivmph,  the  causticity  of  which  attacks  the 
skin,  mucous  membrane  and  bones.  The  exogenous  factor  of 
the  disease  was  at  that  time  only  slightly  hinted  at. 

We  owe  decided  progress  to  Virchow,  who,  in  accordance 
with  his  belief  in  the  importance  of  the  cell,  considered  the  patho- 
logical constitution  which  leads  to  scrofulosis  to  be  a  weakness 
of  certain  parts  or  regions,  such  as  a  certain  incompleteness  in 
the  structure  of  the  glands,  generally  connected  with  an  incom- 
pleteness  in   other  tissues  (skin,    mucous   membrane.    (Sec).     The 


48  SCROFl  LOSIS 

oTowino-  oiands  nt  chiklrt-n  wliifh  are  .siill  iiu'oni[)k"lt.'  oiler, 
according  to  liini.  main  poinis  of  aiiack.  On  ihis  accouni  scrofu- 
losis  is  especially  a  disease  ot  childhood. 

\'ircho\v  described  the  condition  as  inllamniaiory  diathesis, 
which  accords  with  the  diallu-sis  inllanimaioria  alri-ady  advanced 
by  Thomas  White  (17S8). 

Svlvitis  had  already  supposed  a  peculiar  consiiiuiion  oi  the 
lymphatic  system. 

Later  the  conception  of  the  term  lymphatic  diathesis, 
**  Ivmphatism,"  came  into  favour,  especially  amongst  the 
French,  to  denote  the  tendency  to  scrofulosis,  and  at  the  same 
time  its  supposed  character  of  increased  (hereditary)  tendency  to 
swelling  and  change  of  the  lymphatic  tissues. 

Influenced  probably  by  the  external  appearances,  which  show 
hyperplasia  as  the  most  constant  and  most  reliable  symptom  of 
scrofulosis,  thev  saw  in  lymphatism  the  primary  and  inflammatory 
diathesis  induced  by  the  disturbed  functions  of  the  lymph,  and  an 
increased  inclination  to  the  exudative  processes  of  the  skin  and 
mucous  membrane  as  a  consequence  of  it. 

Others  took  the  clinical  observation  more  into  account  that, 
as  a  rule,  skin  and  mucous  affections  prevail  with  younger 
children,  and  changes  in  the  glands  amongst  older  ones,  and  they 
came  to  the  conclusion  that  the  former  were  primary  processes 
and  that  the  latter  were  to  be  considered  as  secondary  processes 
dependent  on  infection,  which,  etiologically,  is  the  more  exact 
conception. 

Later  both  expressions  came  to  be  equally  employed,  and  the 
mistake  crept  in  of  speaking  directly  of  dyscrasia  as  a  blood 
infection  instead  of  diathesis  and  disposition  in  the  same  sense, 
whilst  only  a  predisposition  was  intended  to  be  expressed. 

The  expression  used  by  Hiss,  Pfaundler,  &c.,  "increased 
readiness  for  disease,"  to  denote  diathesis  or  disposition,  seems 
to  me  to  be  well  chosen,  and  its  adoption  might  tend  to  allay 
disputes  which  have  raged  in  the  last  decades  over  the  tuberculous 
disposition,  and  to  cool  the  animus  heated  by  them  ;  for  it  would 
always  bring  to  those  fanatics  of  the  theory  of  disposition — who 
were  inclined  to  divide  mankind  into  two  classes,  the  disposed  and 
the  non-disposed,  in  which  favoured  class  of  non-disposed  all 
precautions  were  unnecessary,  and  for  the  disposed  were  useless — 
the  knowledge  that  we  are  all  predisposed  to  tuberculosis.  The 
difference  is  a  gradual  one,  and  consists  onlv  in  the  more  or  less 
increased  readiness  of  many  individuals,  the  existence  of  which 
readiness  is  not  denied  by  anyone  (see  vSchlueter's  excellent 
treatise). 


CONCKl'J  ION   AND   CKASSIMCATION   OF    SOROI- LI.OSIS  4'J 

Billrolli  .-111(1  r>ii(li-l  lirsf  lil<-l<l  .-III-  nl  ilir  s,-iiiic.<ipiiiM.ii  as 
Virchow.  'I'Ik;  lallcr  (h-scrilx-d  .s(ioliiio.si.s  as  a  constiluti(jnal 
anomaly,  meaning  tliaL  the  lissu(;s  arc  excit(;d  on  very  small 
provocation  to  chanfr(;s  of  partly  inflammatory,  partly  hyper- 
plastic nature,  and  ili.'ii  iIm-v  Ii.-i\(-  l;iini  powers  of  .'idjustmenl,  so 
that  retroi^ressive  metamor[)lioses  easily  take  phu  e,  and,  in  con- 
nection with  these,  local  tuberculosis. 

Baginsky  thinks  it  is  mA  proved,  though  it  may  be  possible, 
that  the  predisposition  is  constitutional,  i.e.,  anatomical,  in  the 
sense  of  Beneke's  hyperplasia,  in  which  the  reduced  relative  size 
of  the  single  organs  and  the  reduced  power  of  work  ccmsequent 
upon  this  of  the  whole  organism  plays  a  great  part.  He  looks 
upon  scrofulosis  as  a  peculiar  condition  of  the  body  to  which 
certain  micro-organisms,  chiefly  the  tubercle  bacillus,  give  the 
possibility  of  the  power  of  adhering  and  of  speedy  progressive 
development.  I  cannot  give  my  support  to  this  theory,  because 
the  predisposition  to  scrofulosis  is  already  described  as  scrofulosis. 

Henoch  has  deviated  from  the  concise  and  local  point  of  view 
of  Virchow.  He  leaves  it  undecided  whether  the  cause  of  the 
disease  is  an  anomaly  of  the  blood  or  of  the  elements  of  the  tissues, 
or  whether  it  may  be  sought  in  both  together. 

Ponfick  (1900)  looks  upon  scrofulosis  as  an  inclination  to 
more  vigorous  exudative  and  proliferative  reaction  which  has 
no  limit  as  to  age  and  is  qualitatively  variable,  and  which  may  be 
traced  to  an  innate  defect  in  the  morphological  and  chemical  com- 
position of  the  child's  organism.  He  produces  no  proofs  to 
support  his  theory. 

Scrofulous  diathesis  has  been  sought  in  the  cell,  in  the 
humours  of  the  body,  everywhere.  It  appears  best  when  stating 
a  hypothesis  to  include  all  possible  agents,  for  then  later,  which- 
ever proves  right,  one  can  always  say,  "  I  said  the  same  before." 

Lately,  the  theory  of  diathesis  has  again  come  prominently 
into  view\  Old  wine  has  been  put  into  new  bottles;  what  was 
formerly  termed  inflammatory  diathesis  has  now  been  named 
exudative  diathesis  by  Czerny.  This  is  more  precise,  but  it  is 
questionable  if  it  be  more  exact. 

Modern  Hypotheses— Exudative  Diathesis. 

For  a  long  time  unsuitable  and  too  plentiful  nourishment  has 
been  connected  with  the  genesis  of  scrofulosis,  partly  by  attri- 
butino-  irritation  of  the  mucous  membrane  of  the  intestine  and 
secondary  swellings  of  the  mesenteric  lymph  glands  to  this  cause. 
Deranged  nutrition  was  spoken  of  amongst  the  Arabs,  especially 

4 


50  SCROFLLOSIS 

Rhazeus,  as  ilie  basis  of  scrofulosis  (v.  Preisich).  Ai  the  same 
lime  bad  or  insufficient  nourishmeni  was  noi  considered  harmful, 
but  thev  attached  great  weight  to  ()ver-nuiriiit)n  (probably  led  to 
it  bv  the  external  view  of  the  exudative  process).  Rabben  said 
(1817)  :  "  .S"/  paupcrri)}ios  exccpcris,  hoc  )iuiln)}}  (scrofulosis)  e.\ 
abuudinitiu  potins  qiiam  ex  inopia  aHincntonini  dcrivandum 
censco/'  and  Rau  (1832)  :  "  With  young  children  the  cure  often 
succeeds  most  easily  by  simple  change  of  diet  "  (by  which  it  is 
not  said  that  the  illness  was  caused  in  the  first  place  by  unsuitable 
nourishmeni). 

It  is  jrenerallv  ae:reed  that  the  nourishment  in  the  lust  vear 
has  a  great  influence  on  the  genesis  of  scrofulosis. 

According  to  some  authors  scrofulosis  is  attributed  to  the 
lack  of  albumin  in  the  nourishment ;  according  to  others  (Monti, 
Sec),  the  preponderance  of  carbohydrates  was  determinative. 
But  the  most  frequent  cause  of  scrofulosis  is  attributed  to  the 
premature  introduction  of  amylaceous  products  with  human  milk 
in  the  infantile  stage,  stuffing  the  children  with  spoon-food  from 
the  first  month  ;  the  pernicious  influence  of  feeding  children  in  the 
first  year  with  bread,  dry  crusts,  and  farinaceous  foods  instead  of 
milk ;  or  later,  the  preponderance  of  bread,  potatoes,  vegetables 
and  pulse  forming  an  excess  of  vegetable  food,  encourages  this 
(Monti). 

Czerny  has  deduced  that  there  is  a  special  predisposition  to 
scrofulosis  which  he  terms  exudative  diathesis  from  improper 
nourishment  and  over-feeding.  This  exudative  diathesis  depends, 
according  to  Czerny  (1909),  on  an  innate  and  clinically  latent 
defect  in  the  composition  of  the  body,  that  is,  on  chemical  pro- 
cesses. This  is  mostly  in  consequence  of  exogenous  mischief, 
and  becomes  manifest  early,  even  in  the  first  weeks  or  months, 
l)y  al:)normal  results  of  nourishment  either  by  loss  of  weight,  in 
spite  of  plentiful  milk,  without  this  loss  being  explained  by  dis- 
turbances in  the  digestive  tract,  or  else  by  a  remarkable  increase 
of  adipose  tissue,  even  when  the  food  is  poor  in  milk.  Outwardly 
the  exudative  diathesis  shows  itself  by  a  mapped  tongue,  by 
seborrhoea,  milk-scurvy,  strofulus,  and  the  ready  formation  of 
sores,  &c.,  &c. 

Czerny  sees  the  cause  of  this  remarkable  behaviour  in  faulty 
endogenous  nutrition  which  he  supposes  to  lie  in  a  peculiar 
disturbance  of  the  adipose  changes,  as  children  who  can  only 
digest  milk-fat  in  very  slight  quantities  always  have  the  signs  of 
exudative  diathesis  in  which  every  sort  of  fattening  is  harmful. 
According  to  this,  the  essential,  and,  at  the  same  time,  the 
standard  oi  the  predisposilion  of  infants  to  exudative  diathesis  is 


CONCKI'TION    AND   CLASS  II- ICATION   OI-"    SCKOI' I  LOSIS  5I 

,'in  innately  low  conclilion  of  iIm-  inrcpiion  nf  assiniih'ilion  for  \\\fi 
I'al  of  animal-milk,  and  as  inan\  (  liildif  n  dn  nol  tliri\f  f*vf*n  at.  llie 
hrcasl,  parlh'  also  of  iIh-  mol  hcr's-milk.  'I'll*-  .■i\ioii)  ihat  has  up 
(ill  now  been  accci)l('tl  llial  mollif-r's-milk  is  tlif  hfsl  food  for 
infants  needs  lo  he  accei^led   willi  some  reservation. 

'The  i-edii(cd  altsoiplion  of  fal  in  rxiidal  i\  <•  diadiesis  has 
been  confirmed  by  two  of  C/.erny's  colleagues,  Sleinitz  and 
Wei,c:ert,.in  the  case  of  two  <  hildren,  and  has  also  been  supported 
1)\'  the  success  of  change  of  dietf 

Food  tlial  is  poor  in  fal,  without  milk  and  eggs,  the  fat  being 
replaced  by  carbohydrates,  or  in  the  case  of  infants  by  small 
(|uantilies  of  milk,  frecjuenlly  |)roduces  a  series  of  the  under- 
mentioned phenomena  of  exudative  diathesis,  and  even  causes  a 
return  of  the  scrofulous  habitus;  whilst,  on  the  other  hand,  they 
may  be  provoked  in  children  with  a  tendency  to  it  by  diet  contain- 
ing fat  and  by  feeding  up  (Czerny).  On  the  other  hand,  a  favour- 
able influence  on  pallor  of  the  skin,  lichen  urticatus,  &c.,  is 
conferred;  but  milk-scurvy  and  eczema  are  less  influenced  and 
require  local  treatment. 

According  to  Pfaundler,  certain  vasomoter,  vasotonic,  and 
neuropathic,  as  well  as  lymphatic  symptoms,  put  dfjwn  to 
exudative  diathesis,  have  very  little,  if  any  effect. 

The  result  of  such  food  is  most  clearly  perceived  by  a  speedy 
and  progressive  reduction  in  weight. 

Czerny 's  statement  that  by  means  of  food  containing  little  fat 
the  scrofulosis  disappears  and  scrofulous  children  are  transformed 
into  "  fine  children  with  tuberculosis  "  meets  with  well-founded 
scepticism ;  for,  as  Pfaundler  rightly  remarks,  something  more 
than  just  the  deprivation  of  milk,  eggs,  and  sugar  are  necessary 
for  this.  Supposing  Czerny's  theory  were  right,  should  we  not 
expect  in  tlie  last  decades,  when  so  much  has  been  expected  from 
nourishment  Avith  milk  and  eggs,  butter  and  meat,  and  all  fatty 
foods,  that  scrofulosis  must  have  enormously  increased  ?  Yet  this 
has  not  been  observed  or  even  stated.  The  opinion  of  P.  Heims 
that  the  periodicity  of  our  views  is  caused  by  periodical  variations 
in  the  organisms  of  different  generations  will  find  few  followers. 

That  defects  of  nourishment  cannot  be  the  only  cause  of  the 
symptoms  of  exudative  diathesis,  of  the  scrofulous  habitus,  and  of 
scrofulous  symptoms,  if  only  for  the  reason  that  from  observa- 
tions made  in  other  quarters,  all  these  svmptoms,  phlvcten^e, 
blepharitis,  eczema,  &c.,  may  be  traced  to  tuberculin  treatment 
without  change  of  food,  and  now  and  again  with  astonishing 
rapidity,  and  even  the  facies  scrofulosa,  give  place  to  a  natural 
appearance  (Epstein,   Ganghofer,   Escherich). 


52  SCROI-LLOSIS 

Tlie  prejudicial  elTects  n{  the  reclmiinn  of  ahsi)rpiit)n  of  fat 
in  exudative  diathesis  is  also  clispiUed  by  others  (Hirks,  L.  and  F. 
Meyer,  Freund). 

According  to  Aschenheini,  the  j)o\ver  of  assiniilaiion  of  carbo- 
hydrates is  reduced  (see  also  Nothmann,  Huessy),  and  acetonuria 
and  mellituria,  and,  according  to  Cobliner,  glycosuria  are  fre- 
cjuently  present  (see  \'ogt,  Simon). 

l^'inkeistein  and  L.  F.  Meyer  impiUe  ii  lo  changes  in  ihs 
salts;  several  cases  of  eczema  and  asthma  which  were  treated  by 
Langstein  by  Finkelstein's  method  with  food  containing  little  salt 
(onlv  the  lifih  pari  of  the  (|uanlilv  of  sail  coniaincd  in  one  litre 
of  whey)  lost  their  eczema  in  a  few  weeks  (p.  3S2). 

If  Czernv's  demonstrations  were  binding  in  former  cases  they 
must  be  accepted  here,  then  Czerny's  theories  would  lose  their 
exclusive  significance. 

W.  Freimd  considers  variations  in  the  changes  of  mineral 
material  wiih  continued  increase  of  excretion  of  ammonia  through 
the  urine  as  the  consequence  of  an  excessive  supply  of  fat. 

Here  we  must  also  mention  the  theory  of  A.  Robin  (de- 
mineralization),  according  to  which  tuberculous  persons  excrete 
more  of  the  components  of  the  urine  than  health}-  persons,  so  that 
their  organism  becomes  poor  in  certain  constituents,  and  this 
poverty  of  mineral  matter  precedes  the  onset  of  this  disease.  This 
theory,  too,  lacks  exact  proof,  and  many  other  questions  on  this 
subject  still  await  further  study  (Senator,  Ott,  Steinitz,  and 
Weigert,   also   G.   Cornet,   "  Die  Tuberculose,"   second  edition, 

PP-  513-514)- 

Besides  improper  nourishment  and  ihe  injury  caused  bv  it 
to  those  predisposed,  Czernv  mentions  as  later  causative  agents 
of  the  exudative  diathesis,  intercurrent  infections,  teething,  vac- 
cination, measles,  and  tuberculin,  in  which  he  regards  the 
assumption  of  a  specific  reaction  of  the  tissues  as  arbitrary. 

Czerny  (190^^)  b'ls  assumed  the  close  connection  (not  the 
causative  agent)  of  exudative  diathesis  with  neuropathic  and 
psychopathic  conditions,  inasmuch  as  the  parents  and  relations 
of  children  with  exudali\e  diathesis  are  alwavs  neuropathic  or 
psychopathic,  and  children  of  highly  nervous  parents  are  seldom 
free  from  exudative  diathesis,  even  if  onl\-  in  a  small  degree. 
The  connection  of  exudative  diathesis  with  the  irritation  of  certain 
regions  is  shown  by  the  fact  that  children  who  have  been  treated 
for  eczema  for  mr)nihs  and  years  will  sometimes  lose  it  rapidly 
by  going  with  the  j^arents,  or,  better  still,  alone  to  a  seaside  home 
or  health  resort ;  or  by  change  of  air  onlv  ;  with  plav  and  occu- 
pation to  divert  them,   these  children   not  infrequentlv  lose  their 


CONCEI'TION    AND   CLASSll-JCAJ  ION   (Jl    SCROFULOSIS  53 

susceplibilily  (o  aslhma  by  a  lliorougli  change  in  ili'ir  condititms 
(jf  lift;  (food,  cdncalion,  \'c,.),  by  w(;aring  wooll'-n  und'i-clrdliing, 
and  by  a  did  containing  fggs,  while  among  such  ciiildrf-n 
slrofuUis  may  be  arbilrarily  evoked. 

Pallor,  widioul.  anaemia,  die  exlraordinary  secret if;n  of  per- 
spiration after  the  least  physicrd  exertion,  diriiMiiiy  of  breathing 
through  the  nose,  and  after  exerti(jn,  as  well  as  the  intense  irrita- 
tion of  the  skin  in  many  children  with  milk-scurvy  and  strofulus 
may  be  referred  to  nervous  inlluences. 

Czernv  even  attributes  catarrh  of  the  upper  air  passages,  when 
it  is  not  dependent  on  infection  or  cold,  and  therefore  is  not  to  be 
avoided  by  precautions  directed  against  a  psychic  and  neuro- 
pathic constitution. 

The  vasomotor  over  excitability  and  neuropathic  constitution 
of  children  of  an  exudative  diathesis,  and  the  angioneuropathic 
nature  of  the  symptoms  which  make  it  evident  (such  as  inflam- 
matory reaction,  eczema,  often  in  symmetrical  arrangement, 
urticaria,  mapped  tongue,  asthma,  &c.)  is  brought  into  pro- 
minence by  other  authors,  especially  Moro. 

Other  Signs  of  Exudative  Diathesis. 

It  is  not  unusual  to  find  in  the  lymphatic  children  of  exuda- 
live  diathesis,  even  in  the  latent  stage,  more  or  less  pronounced, 
hyper-eosinophilia,  which  is  specially  pronounced  in  the  case  of 
eczema. 

But  the  data  vary  even  amongst  healthy  children,  whilst  in 
adults  the  proportions  of  eosinophil  cells  to  the  leucocytes  is  with 
tolerable  conformity  -about  2  to  4  per  cent,  and  o'5  to  4  per 
cent. ;  we  often  find  among  healthv  children  higher  computations 
(Ehrlich,  Lazarus,  Karl,  Meyer,  Jacksch),  even  to  10  per  cent.; 
among  infants,  2*5  to  3*9  per  cent. ;  Rosenstern  found  2  to  3  per 
cent,  of  eosinophils  among  children  at  the  breast,  and  o'7  to  4 
per  cent,  in  those  artificially  fed. 

Much  higher  rates  were  obtained  in  the  examinations  of 
Langstein  (up  to  33  per  cent.),  Helmholtz,  Benjamin,  and  Rosen- 
stern  in  exudative  diathesis,  and  especiallv  in  eczema,  over  10  per 
cent.,  even  20  per  cent,  and  30  per  cent. 

Staubeli  even  speaks  of  eosinophile  diathesis.  Langstein 
leaves  it  uncertain  whether  this  phasis  is  a  svmptom  of  exudative 
diathesis  or  the  local  skin  affection  of  eczema ;  but  Helmholtz 
found  in  two  cases  the  number  of  the  eosinophilia  considerablv 
reduced,  and  L.  F.  ^leyer  observed  here  and  there  a  reduction 
of  the  eosinophilia  with  the  healing  of  eczema,   but  mostly  the 


54  SCROFLLOSIS 

proi")(_>rtion  remains  staiionary,  sd  tliai  he  considered  them  as  one 
of  the  earliest  constant  symptoms  of  asthma. 

\'entura  mentions  hypertrophy  ()f  the  liver  as  one  of  the 
s\mi")loms  he  has  found  with  tolerable  freqiienc}'  in  the  extidative 
diailu'sis. 

It  would  lead  us  too  far  to  go  more  closely  into  the  relation 
of  the  exudative  diathesis  to  the  status  lymphaticus  of  Paltauf- 
Kscherich,  with  which  are  included  a  series  of  symptoms;  or  the 
subordination  of  both,  the  diathesis  and  the  siaius  Uniphalicus, 
bv  Eppinger  and  Hess  in  the  infantile  form  to  the  condition  of 
tone  in  the  vagus;  or  tlie  connection  Axiih  Comby's  rheumatism 
in  children,  and  similar  questions  which  still  need  further 
discussion. 

Reference  must  be  made  to  the  interesting  anatomical  studies 
of  Bartel  and  Stein,  according  to  which,  in  the  status  Ivmphaticus 
of  Paltauf-Escherich,  a  disturbance  takes  place  in  the  develop- 
ment of  the  lymphatic  gland  system,  and  in  the  connective  tissue; 
whether  such  a  disturbance  can  be  taken  into  account  for  the 
exudative  diathesis,  whether  it  rests  on  congenital  inferiority, 
irrital^iliiy,  and  ready  deterioration  of  the  meso-ch^•me  and  its 
derivatives  (Pfaundler)  are  suppositions,  the  proof  of  which  covers 
a  wide  ground. 

As  an  external  sign  of  the  exudative  diathesis  Czerny  in- 
cludes a  mapped  condition  of  tongue  (not  always  a  reliable  sign), 
seborrhoea,  milk-scurvy,  prurigo  or  strofulus,  intertrigo,  sore- 
ness behind  the  auricle,  in  the  folds  of  the  neck  and  armpits,  pro- 
nounced hairiness  between  the  shoulder-blades,  in  the  region  of 
the  elbows  and  on  the  thighs  (Friedjung  describes  a  similar  con- 
dition as  a  sign  of  the  tuberculous  habitus).  Freund  also  mentions 
stiff  tufts  of  hair  which  Pfaundler  describes  elsewhere. 

Further  indications  are  eczema,  impetigo,  vesicular  eruptions, 
caries  of  the  teeth,  diffuse  bronchitis  and  bronchiolitis,  sometimes 
combined  with  asthma;  further,  catarrh  of  the  nose  and  pharynx — 
symptoms  which  are  not  characteristic  of  themselves,  but  become 
so  by  frequent  repetition;  further,  an  increase  of  the  lymphoid 
tissues  of  the  gums,  tonsils,  and  pharynx — blepharitis,  vulvitis, 
balanitis — paleness  of  the  skin  beginning  in  infancy  without 
haimatological  indications  of  auc-emia  and  not  caused  by  improper 
nourishment  or  preceding  illness;  loss  of  appetite  at  times,  some- 
times fever  lasting  several  days,  and  coated  tongue,  with  or  with- 
out disturbance  of  the  general  health,  but  without  the  stomach 
being  affected. 

In  the  case  of  the  intestinal  canal,  Czernv  at  first  only 
acknowledged  the  mapped  tongue  (1905),   and   later  hyperplasia 


CONCICPTION    ANI>   CLASSII' ICA'I  ION  OF    SCKOI' CI/jSIS  55 

of  the  inlcslin.'il  follicles  ns  sij^Mis  ol  ilir  cxudalivf-  diallif-sis,  bui 
Langstein  and  (iocppcii  csinblislicd  slimy  stools  cfjntaining  pus 
to  be  an  external  indic.'ii  ion  ol  ilic  dial  Ixsis  (see  also  Sehlbach). 

Of  the  symptoms  of  exudative  diadicsis  here  Ijrouglil  forwarri 
some  do  not  belong  to  scrofulosis  in  our  sense,  but  they  (such 
as  milk-scurvy)  are  the  Jicknowledged  indications  of  disturbances 
in  nutrition,  and  are  sometimes  the  f)re(iirsors  rtf  scrofulosis  by 
favouring  infectious  processes. 

In  this  connection  Czerny  (who  purposely  avoids  ilie  expres- 
sion "scrofulous"),  to  avoid  controversy  over  the  identity  of 
scrofulosis  with  tuberculosis,  comprises  in  his  conc<-piion  of  tiie 
diathesis  phenomena,  such  as  vesicular  eruptions,  denial  caries, 
blepharitis,  with  which  there  can  be  no  f|uestion  of  diathesis,  and 
readiness  for  illness,  but  which  rightly  and  by  general  consent 
belong  to  fully  developed  scrofulosis,  and  are  consequently  pheno- 
mena of  diathesis  plus  the  infectious  processes  which  have  been 
facilitated  and  maintained  by  it. 

This  is  just  as  little  justifiable  as  if  we  classed  florid  phthisis 
under  our  notion  of  the  term  tuberculous  disposition. 

The  exudative  lymphatic  diathesis  with  its  manifestations 
can  only  be  taken  into  account  as  a  preliminary  stage  of  real 
scrofulosis,  as  a  favourable  field  for  the  development  of  further 
morbid  reaction,  which  itself  is  induced  by  external  irritation,  and 
almost  without  exception  by  bacteria ;  it  is  true  many  symptoms 
that  stand  on  the  boundary  between  diathesis  and  scrofulosis  can 
be  adduced,  e.g.,  eczema  amongst  skin  phenomena,  amongst  affec- 
tions of  the  mucous  membrane,  catarrh  and  hypertrophy  of  the 
tonsils,  now  and  again  perhaps  induced  by  alimentary  irritation, 
overfeeding,  or  errors  of  nutrition.  In  such  cases  bacteria  play 
only  a  secondary  part  by  keeping  up  the  process,  but  it  is  a  con- 
firmed fact  that  for  the  real  scrofulous  phenomena,  and  especially 
for  the  pathognomonic  indication  of  scrofulosis,  the  exceptional 
pathological  processes  must  be  made  answerable,  and  such  pro- 
cesses are  induced  by  bacteria  and  their  toxins  (see  also  previous 
chapter). 

When  Pfaundler  raises  the  question,  whether  exudative 
diathesis  alone  in  concert  with  tuberculous  infection  is  enough 
to  induce  the  tv^pical  phenomena  of  scrofulosis — when  he  at  the 
same  time  emphasizes  the  universal  experience  that  there  are 
plenty  of  children,  especially  amongst  the  better  classes,  who,  in 
spite  of  exudative  diathesis,  in  spite  of  superabundant  nourish- 
ment and  overfeeding,  and  in  spite  of  tuberculous  infection  and 
active  disease,  relatively  seldom  exhibit  the  pronounced  signs  oi 
scrofulosis — there    is,    in    fact,    an    unintentional    and    unwilling 


56  SCKOFLLOSIS 

acknowledgment  of  the  important  part  played  by  the  badly 
treated  pyogenous  scrofulosis,  the  infection  by  dirt,  which  is 
naturally  more  rare  with  the  better  classes,  whereby  the  "  pro- 
nounced cases,"  when  it  is  not  a  question  of  tuluM-culous  glands, 
are  avoided. 

It  will  hardly  be  contested  that  much  of  the  diathesis  theory 
is  completelv  unproved  and  lacks  exact  foundation,  that  much 
remains  to  be  explained  before  the  path  from  Czerny's  "  innate 
defect  "  to  the  complete  phenomenon  of  classical  scrofulosis  can 
be  considered  free  from  doubt. 

One  thing  that  speaks  in  favour  of  this  theory  is  the  fact 
that  preceding  the  development  of  scrofulosis  there  have  been, 
almost  without  exception  even  in  the  infantile  stage,  certain 
indications  of  lymphatism,  of  mapped  tongue,  seborrhoea,  and 
milk-scurvv  conversely,  that  at  the  same  time,  especially  in  the 
first  vear  and  frequently  later,  no  tuberculous  infection  existed,  as 
is  proved  by  the  negative  result  of  the  tuberculin  test,  even  with 
these  children  who  are  so  highly  sensitive  to  reaction. 

Unfortunately,  at  present  we  possess  no  means  similar  to  the 
tuberculin  test  to  prove  the  presence  or  absence  of  pyogenous 
infection.^ 

We  do  not  deny  a  certain  exudative  predisposition,  a  coin- 
cident increased  readiness  for  disease — recognized  by  an  increased 
tendency  to  react  to  irritation,  especially  bacterial  irritation  in 
children  causing  an  obstinate  and  protracted  reaction — but  we 
must  bear  in  mind  that  the  facts  which  have  up  till  now  been 
obtained  give  us  no  insight  into  its  nature ;  whether  we  have  to  do 
with  a  chemical  defect,  or  if  it  be  really  a  disturbance  of  metabolism 
of  the  fatty  matters,  which  is  the  gist  of  Czerny's  theory,  for  it  is 
especially  in  this  direction  that  an  exact  basis  is  lacking. 

Thus,  the  older  notion,  still  retained  by  the  French,  of  a 
lymphatic  constitution,  lymphatism,  has  found  new  followers  in 
Escherich,  Moro,  &:c.,  but  with  the  interpretation  that  it  is  a 
constitutional  anomaly  which  distinguishes  itself  by  a  "  great 
tendency  of  the  organism  to  inflammatory  reaction  of  obstinate 
and  recurrent  nature  (with  exudation  of  lymph)  in  which  the 
lymphatic  tissues  take  a  decided  primary  and  secondary'  part," 
a  conception  somewhat  divergent  from  that  of  the  older  phy- 
sicians— Ilufeland,  Bandeloque — who  find  in  the  lym|:)hatic  tem- 
perament   of    the    lymphatic    constitution     the    only    conclusive 

^  When  therefore  Pfaundlcr  thinks  it  is  possible,  by  excluding  such 
cases  as  react  to  tuberculin,  to  study  the  character  of  genuine  diathesis 
without  complicating  infections,  this  is  not  to  the  point,  as  we  cannot 
exclude  pyogenous  infection. 


CONCEP'IION   ANIJ   CLASSIFJCATKjN   Ol-    SCKOl- (.I/JSIS  57 

reason  for  scrofulosis,  and  define  scrofulosis  as  ilie  liiglif-st  degree 
of  the  slatLis  lyinj)l)ali(:u.s. 

l\igli(ly  nndcM'Slood,  llie  ( onibinal  ion  of  ihe  expression 
lymphatism  willi  iIk;  etiology  of  s(  rofiilosis  is  debatable;  even 
as  a  designati(^n  of  the  cc^llective  s(rofuh)Lis  tendency  I  consider 
it  inappropriate,  because  by  drawing  attention  lo  the  lymphatic 
system  only,  it  is  only  a  part  of  the  tendency,  a  part  of  ilie 
readiness  tliat  is  denoted;  while  it  is  recognized,  as  Virchow  has 
emphasized  in  his  defmiiion,  (hat  a  certain  abnormal  preliminary 
state  of  the  skin  and  the  mucous  membrane  exists  in  a  prominent 
degree,  let  the  cause  be  what  it  may. 

But  even  if  we  accept  the  supposition,  which  is  completely 
unproved,  that  lymphatic  symptoms  are  really  caused  by  the 
scrofulosis,  that  they  are  its  cardinal  point  and  essence  and  not 
symptoms,  where  can  the  boundary  line  between  lymphatism  and 
scrofulosis  be  drawn  ? 

The  designation  "  exudative  diathesis  "  would  be  more 
suitable,  inasmuch  as  it  includes  the  symptoms  of  the  disease 
and  yet  does  not  bind  us  as  to  the  etiology ;  it  at  least  comprises 
the  cycle  of  changes  in  the  skin,  mucous  membranes  and  lymphatic 
glands,  unless  a  strictly  etiological  term  be  preferred. 

The  adherents  of  lymphatism,  Escherich,  Moro,  as  well  as 
Czerny  in  his  exudative  diathesis  theory,  go  beyond  the  mark 
when  they,  without  due  grounds,  designate  a  part  of  the  scrofulous 
phenomena  simply  as  lymphatism,  the  greater  part  of  which  the 
the  facult}^  have  for  centuries  termed  typical  scrofulosis.  Escheric 
and  Moro  remove  the  whole  boundary  line ;  for  them,  Ivmphatism 
is  no  diathesis,  no  readiness  for  lymphatic  processes,  but  the 
process  itself ;  thus  they  exclude  the  greater  part  of  what  everv  one 
understands  by  scrofulosis,  with  the  exception  of  those  affections 
induced  by  tubercle  bacilli.  Scrofulosis  is  onlv  Ivmphatism 
combined  with  tuberculosis ;  the  lymphatic  constitution  is  the 
ground  in  which  an  accidental  tuberculous  infection  will  develop 
scrofulosis. 

Does  Moro  believe  that  all  the  cases  of  non-tuberculous 
scrofulosis  (he  uses  this  expression  once)  arise  without  bacteria, 
and  if  not,  why  does  he  not  state  it  ?  To  what  serious  conse- 
quences, or  rather  inconsequences,  may  this  not  lead  us  ?  Does 
not  the  clinical  aversion  to  bacteria  go  too  far,  and  is  not  a  too 
important  part  ascribed  to  the  exogenous  factor  ? 

Moro  says  it  is  frequently  tuberculin  reaction  alone  which 
enables  us  to  discover  the  non-scrofulous  cases  in  this  class,  for 
the  external  complex  of  symptoms  which  such  children  exhibit 
can,  under  certain  circumstances,  be  so  deceptively  similar  to  those 


58  SCROFULOSIS 

\vhich  characterize  scrofulosis,  that  at  present  no  other  means  v^f 
distinction  by  clinical  examination  can  l)e  used.  This  is  especially 
the  c^se  when  children  exhibit  the  dermatose  habitus  already 
described,  in  the  form  of  chronic  eczema  on  the  face  and  ears, 
impetigo,  or -an  eruption  resembling  lichen  on  the  trunk,  or  when 
inflammation  of  the  lymph  glands,  the  eyelids,  and  the  conjunctiva 
are  present  at  the  same  time. 

Moro  terms  children  with,  as  he  himself  admits,  all  thc^ 
decided  external  symptoms  of  scrofulosis  (with  scrofulous  habitus; 
not  scrofulous  but  lymphatic,  for  the  single  reason  that  they  do 
not  react  positively  to  the  tuberculin  test ;  therefore,  according 
to  Moro,  all  the  old  classical  cases  of  typical  scrofulosis  (one  has 
only  to  read  the  history  of  his  cases  and  their  progress)  (see 
above)  are  not  scrofulous  because  no  tubercle  bacilli  have  come 
into  contact  with  the  organism  is  question;  but  these  individuals 
(he  describes  two  cases)  belong  to  the  scrofulous  class  from  the 
moment  when  the  reaction  becomes  positive.  It  is  all  the  same 
even  if  the  positi\e  reaction  (see  my  cases,  pp.  18-21)  is  induced  bv 
some  latent  focus,  a  small,  completely  inactive  and  already  healed 
bronchial  gland,  caused  perhaps  by  bovine  bacilli,  the  allergic  of 
which  perhaps  remains,  and  so  by  an  accident  that  has  nothing 
whatever  to  do  with  the  phenomena  of  scrofulosis.  Yet  the 
behaviour  of  such  glands  in  scrofulous  children  (according  to 
Moro,  lymphatic  children)  follows  the  same  statistical  law  of 
frequency  as  in  normal  children. 

Is  it  not  turning  logic  upside  down  to  pull  to  pieces  what 
clinical  observation  has  taken  centuries  to  build  up,  in  response 
to  what  are,  at  least  in  many  cases,  irrelevant  accidental  circum- 
stances ? 

Moro  supports  his  opinion  by  two  cases^  affected  with  all 
the  signs  of  scrofulosis  which  reacted  positively  after  a  previous 
negative  reaction  ;  but  in  such  cases,  of  which  there  are  doubtless 
thousands,  the  infection  which  has  taken  place  in  the  meanwhile, 
if  it  had  been  caused  bv  bovine  bacilli,  remains  strictly  localized 
in  the  primary  focus,  and  after  a  while  disappears  without  leaving 
a  trace;  but  when  virulent  bacilli  enter  the  lungs,  phthisis  or 
miliary  tuberculosis  may  ensue,  but  whether  the  bacilli  act  upon 
the  scrofulous  phenomena  already  present  and  change  them  no 
one  can  say.  In  what  way  have  the  signs  of  scrofulosis  which 
are  now  present — the  eczema,  the  impetigo,  and  vesicular  erup- 
tions— changed,  that  one  must  now  call  them  In-  another  name? 

^  ^Toro  says  after  discussing  the  two  cases,  "  Such  observations  lead  us 
to  think  that  there  must  be  some  genetic  connection  between  lymphatism 
and  tuberculosis." 


CONCICl'TK^N    AND   CLASSIl' ICATION   OF    SCROI' L  LOSJS  59 

To  mv  mind  I  lie  .-u  (  ci)!,-!!  ion  of  Morn's  pomi  of  view  W(juld 
only  bring  nior*-  (<»nlii,sion  inio  iliis  alicad}  ol)s<  iir'-  (|Mr-siion 
instead  of  making  il  nmif  <  Icar. 

vSollmann  brings  forward  a  completely  (Jilferenl  (Opinion- 
He  considers  scrofulosis  an  hereditary,  non-bacillary  toxic 
tuberculosis;  according  to  his  view  the  normal  placenta  forms 
a  filter  for  corpuscular  elements,  which  it  retains,  and  alUnvs  of 
no  return  when  il  is  diseased,  injured  or  eroded;  but  lo  matter 
in  solution  the  iniact  placenta  allows  free  passage.  Soltmann 
thinks  that  in  tuberculous  persons  ilu-  products  of  the  changes 
of  the  tissues  and  liie  debris  of  bacilli  uhich  are  in  solution 
— the  tuberculous  toxins — pass  over  from  the  tuberculous  mother 
in  the  foetal  stage,  and  by  their  chemotactic  effects  induce 
lasting  toxic  symptoms.  According  to  which,  that  which 
one  designates  hereditary  disposition  to  tuberculosis  is  hereditary 
diathesis,  and  the  time  of  its  appearance,  and  the  way  the  conse- 
quences will  manifest  themselves,  depends  on  how  much  material 
for  defence  there  is  at  the  time  of  birth. 

Soltmann's  idea  has  at  first  view  something  fascinatingly 
simple  in  it,  for  it  is  known  that  toxins  can  produce  changes 
similar  in  many  respects  to  scrofulosis.  A  plausible  explanation 
was  found  for  the  sluggish  course,  different  from  that  of  the  usual 
bacillary  infections,  for  the  appearance  of  tuberculides  and  a  series 
of  phenomena  which  present  difficulties,  also  for  the  not  rare  fact 
of  scrofulous  children  being  descended  from  tuberculous  parents 
and  the  fact  of  scrofulosis  running  in  families.  At  the  same  time 
important  considerations  tell  against  it ;  in  the  first  place,  scrofu- 
losis does  not  appear  immediately  after  birth,  but  mostly  at  the 
end  of  the  second  half-vear  and  in  the  second  year,  and  also 
tuberculin  reaction  (a  fact  which  is  of  great  importance)  appears 
very  seldom  in  the  first  year  when  the  toxin  must  be  most  opera- 
tive, more  frequentlv  from  the  second  vear,  when  an  elimination 
of  the  toxin  mav  be  expected;  further,  though  truly  scrofulous 
children  often  descend  from  tuberculous  mothers,  but  very  fre- 
quentlv from  non-tuberculous  also  and  judging  from  the  total, 
relatively  seldom  from  tuberculous  mothers,^  so  that  the  conditio 
sine  qua  non  of  Soltmann's  representation  of  the  matter  does  not 
agree  with  the  generally  accepted  idea  of  the  defensive  action  of 
the  toxin  ag-ainst  fresh  infection  on  the  one  hand,  and  the  not 
infrequent  later  appearance  of  tuberculosis  of  the  lungs  in 
the  scrofulous  on  the  other  hand;  also  the  frequent  proof  of 
bacilli  in  the  scrofulous  changes  contradicts  a  pure  toxic  genesis; 

1  Mothers  wlio  are  tuberculous  at  the  time  of  the  birth. 


6o  SCROFULOSIS 

a  series  of  reasons  which   forces  us  to  reject   the  hypothesis  of 
Sohmann. 

A  further  hypothesis,  based  on  the  doctrine  of  Behring-,  may 
1h"  mentioned,  lie  looks  upim  scrofulosis  as  the  clinical  expres- 
sion of  tiie  tuberculous  diathesis  induced  by  a  special  method  of 
infection  cither  b\'  rej^eatcd  hycxTinfcciion  or  by  a  very  long  latent 
stage. 

ENDOGENOUS  FACTOR— LOCALIZED   DIATHESIS. 

For  the  present  no  conclusive  proofs  arc  to  hand  to  cause 
us  to  accept  diathesis  affecting  the  whole  body  as  a  preparation 
for  an  attack  of  scrofulosis,  but  at  the  same  time,  as  there  is  no 
proof  to  the  contrary,  I  have  no  reason  to  deny  it. 

But,  then,  must  the  endogenous  agent  be  dispersed  over  the 
whole  organism  ?  Is  it  not  more  reasonable  to  seek,  like  Virchow, 
this  anomaly  in  the  nearest  organ  affected,  and  so,  in  the  first 
place,  in  the  lymph  glands  ? 

The  erroneous  opinion  that  the  receptivity  for  the  disease 
and  the  constitutional  anomalies  must  always  be  universal  in  their 
nature  is  a  legacy  from  the  humoural  pathology,  and  is  caused  by 
the  fact  that  diathesis  and  dyscrasia  are  mistaken  for  one  another. 
I  have  already  mentioned  in  my  former  treatises  on  tuberculosis 
that — in  opposition  to  the  general  disposition  to  tuberculosis 
mostly  accepted,  for  which  till  now  there  are  no  proofs — for  the 
local  disposition  a  series  of  positive  bases  are  to  hand.  Martius 
has  recently,  in  his  large  treatise,  laid  special  stress  on  these 
strictly  localized  constitutional  anomalies. 

In  scrofulosis  the  whole  of  the  lymphatic  system,  and  even 
the  lymph  glands  of  one  region  of  the  body,  are  not  attacked  at 
the  same  time  but  bv  degrees,  and  the  process  always  occurs  at 
the  outer  or  inner  surface  of  the  body  which  lie  nearest.  This 
observation  leads  us  to  further  consider  whether,  because  the 
noxious  material  intrudes  itself  from  the  periphery,  the  state  if 
predisposition  to  scrofulosis  is  not  to  be  placed  at  the  periphery 
of  the  body,  at  the  origin  of  the  lymphatics,  which  is  also  often 
much  earlier  attacked  than  the  glands.  As  a  fact,  the  lymph 
glands  are  nothing  more  than  passive  reservoirs  for  the  tribu- 
tary area  and  their  behaviour  and  reaction  is  entirely  dependent 
on  that  which  is  conducted  to  them  by  the  vasa  afferentia. 
It  depends  in  the  first  place  upon  their  anatomical  position  and 
their  communication  with  the  place  of  inoculation  whether  thev 
take  part  sooner  or  later  in  the  infection.  Do  we  ascribe  a  special 
long   pre-existing   tendency  to   glands    wliicli    become   syphilitic 


CONCKPTION    AND   (;I,A.S.SIMC;A  HON  ()[•    SCKOMLOSIS  6  I 

or  cancerous,  ov  do  wc  noL  rather  see  in  it  a  c(;in[jl<Hely  natural 
and  necessary  consec|uence  of  the  immigrant  toxin  ? 

'I'herefore  we  can  spe.'ik  of  .-in  increased  tendency  of  a  certain 
group  of  glands  to  tuberculous  poison,  just  as  little  as  we  can 
attribute  to  a  lake  a  tendency  to  receive  its  tributary  streams  and 
the  materials  wliicii  they  contain. 

The  first  ihinq-  we  have  to  settle  is  how  far  a  different  con- 
slilulion  of  ihc  skin,  mucous  membrane,  and  the  lymph  vessels 
l('a(hn<4  lo  ihcm,  is  capable  of  explaining  (he  scrofulous  lendenc)'. 

Anatomical  Explanation  of  the  Tendency  of 
Scrofulosis. 

Skin  and  niucous  membrane  fcjrm  the  protective  covering  of 
the  inner  organs  through  which  bacteria  must  force  themselves  U) 
enter  the  body.  As  we  can  judge  by  the  size  and  quantity  of 
the  solid  substances  passed  through  a  filter  of  its  width  or  narrow- 
ness, of  its  openings  and  canals,  and  its  permeability,  so  we  can 
just  as  rightly  draw  conclusions  as  to  how  often  or  how  seldom 
germs  enter  the  body  by  the  more  or  less  permeability  of  the  skin 
and  mucous  membrane. 

Hueter  (1872),  at  the  time  when  the  theory  of  bacteria  lay  in 
darkness,  touched  upon  the  incomplete  and  defective  formation 
of  the  protecting  epidermis  and  epithelial  layers  in  different 
persons  as  a  part  of  the  scrofulous  tendency — it  is  true  only  as  a 
supposition  and  without  experimental  confirmation.  He  refers 
to  the  microscopic  phenomenon  that,  besides  the  sweat  and  fat 
glands  of  the  epidermis,  and  the  mucous  glands  and  the  follicles 
of  the  mucous  membrane,  fine  pore  channels  are  visible  between 
the  epithelial  and  epidermal  cells;  the  different  sizes  of  these 
channels  in  different  persons  afford  as  a  natural  corollary  a  greater 
or  less  possibility  of  the  intrusion  of  micro-organisms. 

So  the  tendency  to  a  repetition  of  inflammatory  processes, 
which  has  been  attributed  to  scrofulosis,  the  increased  vulnera- 
bility and  irritability,  as  well  as  the  recrudescence,  would  be 
accounted  for  by  an  easier  intrusion  of  bacilli.  Just  so  we  have 
the  cause  for  the  easier  dispersal  of  the  exciting  agent,  i.e.,  the 
tendency  of  the  inflammation  which  has  arisen,  to  expand  itself 
both  as  to  space  and  time,  the  chronicity — which  is  also  a  sign 
of  scrofulous  individuals — in  the  extended  channels  of  the 
lymphatic  system  and  of  the  ducts  of  the  blood  circulation,  if 
we  may  suppose  the  abnormal  volume  of  these  pores  to  indicate 
an  equal  expansion  of  the  lymphatic  system  which  is  in  connection 
with  them.      At  present  we  have   no  reliable  anatomical   proofs 


.62  SCROFLLOSIS 

for  the  greater  permeability  of  the  skin  and  nuicous  membrane 
in  manv  individuals  being  one  of  the  real  factors  of  the  tendency 
to  scrofulosis,  but  to  deny  it  off-hand  on  account  of  this  is  just 
as  unjustifiable,  because  the  particulars  on  which  the  theory  is 
based,  the  permeability  of  the  skin  and  mucous  membrane,  the 
individual  variations  of  this  permeability  according-  to  age  and 
sex  are  based  partlv  on  hundreds  of  experiments  on  animals, 
partlv  on  well-known  facts,  anatomical  examinations,  clinical 
reports,  and  tind  acceptation  with  \'irchow,  Ilueter,  &:c.  In  any 
case,  it  is  better  confirmed  than  the  chemical  defect  of  exudative 
diathesis,  which  has  many  times  been  willingly  accepted  without 
other  chemical  proofs  being  adduced  than  the  authoritative  assur- 
ances of  its  originator. 

^hinti  accounts  for  scrofulosis  as  a  faulty  histological  struc- 
ture with  defecti\-e  metabolism.  \^irchow  believes  that  tissues 
which  are  rich  in  Ivmph  are  more  easily  accessil:)le  to  infection. 
Ponhck  agrees  with  me  that  there  is  a  pyogenous  tuberculous 
mixed  infection,  and  he  attributes  the  easier  deluging  of  the 
infantile  tissue  with  bacterial  germs  to  the  more  plentiful  presence 
of  Ivmph,  the  greater  power  of  extension  of  the  lymph  glands 
and  the  greater  power  of  rapid  growth.  Preisich  mentions  hyper- 
plasia of  the  Ivmph  glands  as  the  foundation  of  scrofulosis,  w  hich 
readilv  leads  to  expansion  of  the  lymph  spaces  and  vessels,  the 
consequence  of  which  is  Virchow's  vulnerability;  whilst  I  put 
infection  (which  is  simply  its  introduction),  instead  of  vulnera- 
bility. Moro  and  Czerny,  on  the  contrary,  exclude  the  inter- 
pretation of  diathesis  in  the  sense  of  a  slighter  infection,  but 
imforlunatelv  they  withhold  their  reasons  against  it. 

Is  it  not  a  fact  that  has  long  been  confirmed,  that  constitu- 
tional disturbances  of  any  sort  on  the  surface  are  the  forerunners 
of  scrofulosis  and  favour  infection,  and  to  these  disturbances 
seborrhoea,  eczema  and  lichen  urticatus  belong? 

Do  not  manv  clinical  professors  go  too  far  wlicn  tlicx  put  in 
the  background  everything  connected  willi  infcclion  and  show 
their  pariialitv  to  the  endogenous  factor  bv  placing  it  in  the 
foreground  ? 

(1)  PERMEABILITY  OF  THE  SKIN  AND  MUCOUS  MEMBRANES. 

The  protection  afforded  to  the  internal  organs  bv  the  skin  and 
mucous  membranes  is  not  always  absolute  nor  the  same  even 
under  normal  circumstances. 

There  are  two  things  which  we  must  keep  apart  :  (i)  The 
intrusion  of  organisms  into  the  intact  surface;  (2)  the  permeability 
of  the  skin,  that  is  the  property  of  allowing  bacteria  to  penetrate 
through  the  covering  into  the  tissues  lying  beneath  it. 


CONCEI'TJON   AND  Cl.ASSII' ICA'I  JON  OI-    SCROFULOSIS  63 

The  pcrmc'iltiiil  v  li.'i.s  Ix'cii  imikIi  (|iifsl  k  .iK-d,  111  (■a.s'^s  ni 
necessily  il  has  been  allowed  ili;ii  Ii.-k  kti.-i  m.-iy  iiis'Ti  I licmselves 
ihroLigli  small  wounds  in  iIm-  citidcrnin  and  fpidiclial  covering', 
also  lliaL  under  cerlnin  ciic  unisianecs  an  invasion  ol  bacifria  may 
take  place  lliroUL;li  die  iniacl  surface,  liui  "lor  die  ^n-nesis  of 
scrofulous  glands  a  previous  lesion  of  (lie  surface  oi  the  body  " 
was  a  fundanienlal  condition.  Velpeau  was  llie  first  to  leach  that 
every  swelling  of  (he  l\nipha(ic  glands  \\;is  die  <  ()nse(|iK^nce  of 
inflammation  in  (he  area  of  their  source;  and  Haginsky  and  others 
said  "  (here  is  no  swelling  oi  a  gland  \vi(h  a  prim.'iry  scrofulous 
affection  of  that  organ  from  which  die  lympli-siream  (lows  to  the 
affected  part  of  (he  gland." 

The  penetrability  of  macroscopiccill\  iimnjiiied  mucous 
membrane  was  first  pro\-ed  by  me  after  hundreds  of  experiments 
on  animals  (see  G.  Cornet,  "  Die  Tuberculose,"  first  edition, 
p.  58;  second  edition,  pp.  131-139).  I  note  this  especially,  as  it  is 
customary  to  refer  to  authors,  who  a  decade  later  have  confirmed 
mv  proofs  by  a  few  experiments  (see  also  Berliner  kliu.  U^ochen- 
schrijt,    1904,   p.   153,   and  discussion). 

When  I  have  placed  tuberculous  sputum  or  pure  culture  on 
the  mucous  membrane  of  the  conjunctiva,  the  nose,  in  the  vagina, 
or  on  the  penis,  as  a  rule  infection  of  the  animal  followed, 
especially  if  the  infectious  material  was  rubbed  in.  Manv  times, 
after  further  observation,  the  mucous  membrane  itself  remained 
intact  till  the  death  of  the  animal  without  any  changes ;  the  process 
of  the  disease  first  showed  itself  in  the  lymphatic  gland  nearest  to 
the  part  of  the  mucous  membrane  affected,  and  thence  spread  over 
the  body  if  the  animal  lived  long  enough. 

In  the  same  way  I  was  able  in  inhalation  experiments  with 
fluid  or  dried  sputum  to  prove  tuberculous  disease  in  the  bronchial 
glands  of  animals  without  the  lungs  exhibiting  anv  change  what- 
ever. Dobroklonsky  has  proved  histologically  the  permeability 
of  the  intestinal  mucous  membrane  (see  G.  Cornet,  "  Die  Tuber- 
culose," second  edition,  p.  236).  In  feeding  experiments  tuber- 
culosis of  the  mesenteric  gland  was  the  consequence;  the  mucous 
membrane  of  the  intestine  remained  intact. 

Orth's  experiments  lead  to  the  same  results. 

Tangl,  influenced  by  v.  Baumgarten,  repeated  mv  experi- 
ments, and  admitted  the  possibility  of  the  introduction  of  tubercle 
bacilli  into  the  body  without  causing  tuberculous  changes  at  the 
place  of  entry,  though  he  qualifies  the  admission  bv  adding  that, 
as  a  rule,  it  is  not  so. 

Later  a  treatise  was  issued  from  Fliigge's  Institution  in  which 
the  infection  of  the  bronchial  glands  by  inhalation,  without  tuber- 
culosis of  the  lungs,  was  specialh'  noted. 


64  SCROFULOSIS 

Under  the  intluence  of  v.  Behring's  doctrine  of  ingestion 
tuberculosis,  the  ix'rnieal)ility  of  the  mucous  membrane  was  re- 
tested  bv  L'lTenheimer.  Bariel,  Nebelthau,  Ficker,  Klemenko,  H. 
Reichenbach  and  Bock,  Courmonl  and  Lesieur,  \'ansteenbergbe 
and  almost  without  exception  confirmed.  I  lay  the  greater  stress 
on  this,  as  mv  statement  of  the  permeability  of  the  skin  was 
questioned  by  Bollinger,  Schmidt,  v.  Baumgarten,  Fliigge,  &c. ; 
even  the  macroscopically  uninjured  cutis  appears  mostly,  though 
not  alwavs,  to  be  absolutely  impermeable.  For  in  many  experi- 
ments I  have  succeeded  in  obtaining  tubercuU)sis  of  the  neck 
glands  l\v  cutaneous  rubl)ing  of  the  head  with  tuberculous 
material,  whilst  the  place  where  it  was  rubbed  in  showed  no 
change,  with  the  exception  of  a  little  scale  on  the  nose. 

For  similar  experiments  with  other  bacteria  by  Roth  see 
p.  76. 

It  is  also  proved  that  under  certain  circumstances  by  friction, 
and  now  and  again  by  contact,  bacteria  can  force  themselves  into 
the  uninjured  skin  and  mucous  membrane,  and  even  through 
it,  and  can  get  to  the  nearest  gland  without  leaving  any  changes 
at  the  place  of  entry  due  to  the  tubercle  bacilli.  This  per- 
meability has  been  confirmed  by  observations  in  man,  but  the 
best  proof  would  be  on  an  actual  case  of  scrofulosis ;  but  I  will  not 
base  mv  theories  on  it  here,  to  avoid  falling  into  that  fault  in  logic, 
a  proof  "  ex  petitis  principiis."  But  I  will  mention  the  w^ell- 
known  observations  of  the  penetration  of  far  larger  particles  of 
carbon  into  the  bronchial  glands  wlien  the  mucous  membrane  of 
the  lungs  is  intact. 

(2)  VARIATION  IN  THE  PERMEABILITY  OF  SKIN  ACCORDING 

TO  AGE. 

The  skin  and  mucous  membrane  is  with  different  individuals 
not  of  the  same  nature  anatomically,  and  in  the  same  individual  is 
macroscopically  very  different  according  to  age.  As  the  differ- 
ence in  the  skin  of  a  child  from  that  of  an  adult  is  one  of  the  bases 
of  our  theories  on  the  nature  of  scrofulosis,  which  appears  almost 
without  exception  in  youth,  we  must  devote  more  careful  atten- 
tion to  it. 

A.— ANATOMICAL  DIFFERENCES. 
(1)  Skin. 

In  the  child  the  skin  is  thin  and  tender,  the  blood-vessels  are 
seen  through  it,  and,  on  account  of  the  peripheral  growth  of  the 
tissues  lying  beneath  it,  it  is  in  a  state  of  continual  tension.  As 
the  years  go  on  it  becomes  thicker  and  coarser,  and  in  old  age 


CONCKPTION    AND   CLASSU' ICATION   OI'    SCKOl-LLOSIS  O5 

shrivelled  and  puckered  on  accuunl  of  die  disappearance  of  die 
fat.  Tills  dilference  bec(;mes  accentuated  at  the  end  of  the  period 
of  growth,  at  llie  lime  when  scrofulosis  rarely  develops  for  the 
first  time. 

Also  hislologicaily  many  differences,  according  to  age  and 
the  part  of  the  b(jdy,  are  known  in  the  skin,  especially  since 
Tanzer's  staining  by  orcein,  recommended  by  L'nna,  has  made 
the  study  of  the  elastic  fibres  more  easy. 

Blaschko's  researches  have  confirmed  tlie  fact  that  the  develop- 
ment of  the  epithelial  structures  increases  with  age,  a  condition 
which  is  attributable  to  formative  stimulation  dependent  on  out- 
ward conditions,  such  as  working  with  the  hands  or  pressure  on 
the  soles  of  the  feet  in  walking. 

Blaschko  and  others  have  proved  that  the  epithelial  cones 
represent  transverse  sections  of  layers  which  grow  luxuriantly 
from  the  epidermis  towards  the  cutis;  a  system  of  ridges  laid 
crosswise  and  lengthwise  which  may  be  likened  to  a  honeycomb 
with  different  sized  cells,  and  he  thinks  it  very  probable  that 
the  network  of  the  epithelial  ridges  is  stretched  in  the  same 
direction  as-  the  pull  of  the  muscle,  therefore  is  in  a  state  of  con- 
tinual motion  backwards  and  forwards.  This  circumstance  may 
•  possibly  not  be  Avithout  significance  for  the  admission  of  sub- 
stances into  the  skin. 

According  to  Lowy,  preparations  of  the  skin  of  new-born 
infants  exhibit  a  system  of  ridges  mostly  arranged  according  to 
the  growth  of  the  hair ;  after  a  few  years  a  considerable  change 
may  be  noticed.  In  the  neighbourhood  of  the  mouth,  on  the 
cheeks,  the  chin,  and  the  forehead  this  network  can  no  longer  be 
perceived,  and  only  slight  indications  of  remains  of  the  ridges 
exist  as  evidences  of  their  former  presence.  In  all  the  preparations 
from  children  a  few  months  old  well  developed  ridges  are  to  be 
seen  as  a  network  almost  completelv  closed. 

In  old  age,  on  the  contrary,  a  connected  network  is  no  longer 
found ;  with  advancing  age  the  papilla  disappear,  and  later  the 
atrophy  of  age  asserts  itself.  But,  as  Lowy  remarks,  there  are 
great  differences  in  individuals. 

Without  speculating  upon  the  relation  of  tliese  histologicrd 
differences  to  the  tendency  to  scrofulosis,  I  will  here  only  mention 
the  existence  of  such  differences  according  to  age  and  individuals. 

As  far  as  I  know,  no  histological  proofs  have  been  adduced 
to  show  the  relation  of  individual  differences  in  the  size  of  the 
stomata  and  the  pores  and  the  width  of  the  lymphatic  vessels  to 
the  predisposition  to  scrofulosis.  But  in  this  direction  an  ex- 
tremely slight  difference  can  play  a  verv  important  part,  especially 
5 


66  SCROFULOSIS 

with  regard  to  a  predisposilion  lo  scrotulosis  and  facilitalioi;- 
infection.  For  example,  the  tubercle  bacilli  measure  o"ooi5  mm. 
in  length,  therefore  a  transverse  section  measures  hardly  o'oooj 
mm.,  and  a  stoma  or  a  lymph  canal,  which  is  o'ooooi  mm.  nar- 
rower or  wider  than  another  normal  one,  olTers  considerably  either 
less  or  more  favourable  conditions  for  their  entry  and  conveyance. 
But  this  difference  (which  is  of  the  highest  importance)  escapes 
our  eye,  even  when  furnished  with  the  latest  optical  resources, 
it  being  accustomed  to  entirely  different  conditions  of  measure- 
ment. 

(2)  Mucous  Membranes. 

The  same  differences  according  to  age  are  to  be  noted  in  the 
mucous  membranes.  As  extremes,  I  would  refer  to  the  mucous 
lining  of  the  stomach  of  an  infant  and  that  of  a  drunkard,  of  the 
vaginal  mucous  membrane  of  a  little  girl,  and  that  of  an  aged 
multipara  and  the  infinite  intermediate  stages. 

Ficker  has  proved  experimentally  the  difference  in  the  per- 
meability of  the  mucous  membrane  in  youth  and  age.  With 
young  sucking  rabbits,  after  inhalation  of  Bacillus  prodigiosus, 
germs  were  without  exception  proved  to  be  in  the  blood.  With 
full-grown  rabbits  they  reached  the  periphery  of  the  lungs,  but  did 
not  enter  the  blood.  Also  after  feeding,  germs  were  found  in  the 
blood  and  the  organs  of  the  young  rabbits,  but  only  in  a  few  of 
the  older  ones,  and  not  in  full-grown  dogs  and  cats.  Ficker  makes 
a  mistake  when  he  thinks  that  it  is  only  Weigert  who  has  men- 
tioned these  differences  according  to  age  as  being  probable;  it  is, 
rather,  I,  who  have  stated  them  most  emphatically  in  the  first 
editions  of  my  "  Tuberculosis  "  and  of  my  "  Scrofulosis." 

B.— CLINICAL  PROOFS  OF  THE  GREATER 
PERMEABILITY    OF    THE    SKIN    IN    THE    YOUNG. 

In  young  children  it  is  known  that  the  particles  of  carbon 
inhaled  are  stored  up,  not  in  the  mucous  membrane  of  the  lungs, 
but  principally  in  the  bronchial  glands ;  but  in  later  years  more 
particles  of  carbon  remain  in  the  mucous  membrane  itself  and  in 
the  passages  to  the  glands  and  the  interstitial  tissues.  It  is  clear 
that  in  adults  the  conducting  lymph  vessels  are  more  or  less 
choked  up  and  closed,  partly  perhaps  by  the  former  deposits  and 
the  irritation  caused  by  them. 

There  is  no  difference  between  the  particles  of  carbon  and 
bacteria.  We  take  the  tubercle  bacillus  as  our  principal  example, 
not  only  on  account  of  its  particular  relation  to  scrofulosis,  but 


CONCEPTION   ANJ)  CLASSll'ICAHTJiN   Ol'    SCKOl' CLOSIS  67 

also  because  (^f  its  niinuLeness,   and  hc^caiise   its  conditions  liave 
been  l)est  invesligated  bolli  clinically  and  ex|)eriinentally. 

In  childhood  the;  liilxTcle  bacilli,  wh(;n  diey  j)fnetrate  by 
inhalation,  enter  into  the  deep  recesses  of  the;  lungs  in  very  minute 
quantities,  but  they  enter  compl(;tely  into  the  glands,  and  these 
set  up  tuberculosis  of  the  bronchial  glands,  also  designated 
scrofulosis;  llie  lung  remains  intact,  or  is  only  infected  later  by 
the  rupture  of  the  glands.  On  lliis  account  it  is  frequently 
localized  in  children  in  the  middle  lobe  in  contradistinction  io 
tuberculosis  of  the  apices  of  the  lungs  in  adults.  With  adults, 
on  the  other  hand,  the  germs  are  retained  in  the  mucous  membrane 
itself,  and  in  the  lymph  canals ;  they  induce  there  primary  tuber- 
culosis of  the  lungs  and  cause  tuberculosis  of  the  bronchial  glands 
as  a  secondary  consequence,  sometimes  even  with  fully  developed 
tuberculosis  of  the  lungs;  in  older  persons  the  bronchial  glands  are 
attacked  very  slightly  or  not  at  all.  Exceptions  to  this  rule  are 
rare.  Nowack  mentions  the  case  of  a  woman  aged  6i  with  primary 
tuberculosis  of  the  bronchial  glands. 

The  infection  of  other  parts  of  the  body  follows  the  same  rule. 
In  youth,  for  example,  we  find  tuberculous  neck  glands  without 
meeting  with  other  tubercular  changes  in  the  region  that  caused 
it,  as  far  as  the  mucous  membrane  is  concerned.  The  bacilli  have 
all  wandered  through  the  mucous  membrane.  Usually  it  is  only 
in  small  quantities  (for  the  influence  of  quantity  see  below),  and 
they  only  find  a  hindrance  to  their  progress  in  the  narrower 
filtering  tissues  of  the  glands.  Local  tuberculous  affections  of 
the  mucous  membrane — of  the  tongue,  mouth,  pharynx,  and  nose 
— affect,  as  a  rule,  older  persons,  or  at  least  adults.  With  them 
•the  glands  generally  only  become  affected  by  advanced  processes, 
that  is,  by  the  greater  increase  of  the  bacilli. 

In  the  same  way  it  is  well  known  that  in  tuberculosis  of  the 
mesenteric  glands  in  children,  which  we  must  attribute  to  infec- 
i:ion  of  the  intestinal  mucous  membrane,  frequently  the  intestinal 
mucosa  itself  is  not  affected ;  in  adults  ulcers  of  the  intestine  pre- 
ponderate. Tuberculosis  of  the  lymph  vessels  is  also  more 
frequent  with  them  than  with  children,  but  then  the  Ivmph  glands 
belonging  to  them  are  relatively  smaller  and  show  secondary 
changes. 

Thus  everywhere  we  find  it  clinically  confirmed  that  in  child- 
hood there  is  an  easier  passage  of  the  tubercle  bacilli  through  the 
mucous  membranes  to  the  glands.  In  later  life,  on  the  other 
hand,  a  more  difficult  passage  through  the  mucous  membranes 
■and  a  retention  of  the  bacilli  in  them. 

The  conditions  in  the  skin  are  somewhat  different,  as  mav  be 


68  SCROFULOSIS 

readily  conceived  from  ils  analoinical  consiiiuiion.  The  intact 
skin,  in  adults  and  children,  is  much  less  permeable  than  the 
mucous  membrane,  and  that  of  adults  and  older  persons  is  the  least 
permeable.  Clinical  proofs  :  whilst  the  particles  of  carbi)n  which 
have  intruded. themselves  into  the  mucous  membrane  oi  the  lungs 
partly  arrive  as  far  as  the  glands,  we  do  not  lind  deposits  of 
carbon  worth  mentioning  in  the  ulnar  and  axillary  glands,  even 
of  persons  who  are  handling  coal  all  day. 

If  the  skin  of  a  child  come  into  contact  with  ttibercle  bacilli, 
e.g.,  with  tubercular  sputum,  it  olTers,  as  a  rule,  suilicient  pro- 
tection when  there  is  no  disturbance  of  the  continuity,  but  should 
there  be  slight  epidermal  injuries,  or  if  a  quantity  of  the  material 
of  injection  comes  into  intimate  contact  with  the  skin,  one  or 
another  bacillus  can  insinuate  itself  and  cause  lupus,  which, 
according  to  experience,  mostly  happens  in  youth,  and,  we  add 
at  c~)nce,  m(jre  in  the  female  than  the  male  sex,  when  it  declares 
itself  in  later  years.  The  beginning  can  mostly  be  traced  back  to 
youth. 

The  epidermis  of  adults,  which  is  much  less  permeable,  only 
very  rarely  allows  of  the  intrusion  of  the  tubercle  bacilli,  in  an 
uninjured  condition,  even  when  large  quantities  are  present,  else 
all  anatomists,  nurses  of  tuberculous  cases,  and  slaughterers 
would  have  their  hands  full  of  tubercles. 

But  should  one  small  lesion  exceptionally  occur,  as  is  often 
the  case  with  persons  whose  occupation  constantly  brings  them  in 
contact  with  parts  of  corpses  which  are  tuberculous  (anatomists), 
no  lupoid  focus  would  be  formed  extending  itself  peripherally, 
but  a  post-mortem  tubercle  which  generallv  reniains  strictly 
localized,  and  seldom  includes  the  glands  in  the  processes  of  the 
disease. 

These  are  not  to  be  compared  with  tuberculous  processes 
which  form  in  the  mouth  and  rectum  of  phthisical  persons  when 
in  constant  contact  with  infectious  material,  and  aided  by  the 
erosion  produced  by  their  chemical  irritation. 

Besides  the  lesser  permeabilitv  of  the  skin  in  later  years,  its 
denser  tissue  hinders  a  dispersal  of  the  germs  in  the  vicinity. 
Where  tuberculosis  of  the  glands,  and  even  death,  follows  in  con- 
sequence of  infection  from  a  dead  subject — cases  such  as  we  have 
mentioned  in  a  former  volume — it  is  connected  mostlv  with  some 
simultaneous  defect  and  wound,  some  unusual  favouring  circum- 
stances, mostly  in  \oung  students  or  young  doctors,  or  from  some 
tuberculosis  from  inhalation  which  has  arisen  through  a  com- 
pletely independent  local  affection. 

The    tuberculosis    verrucosa    cutis    described   bv    Riehl    and 


CONCKl'TION    AND   Cr.A.SSIFICATION  OF    SCKOl- LUjSIS  69 

PaUauf,  vvlii(  li  cm  nlso  Ix;  traced  lo  ili'-  rf;f)fale(l  liandlin^  of 
tuberculous  .-minials  or  olli(;r  materials,  disi  in^niislics  ilsflf  by  if.s 
local  cliaraclcr.  'IIk;  glands  are  seldom  :\\)'c(\c(\,  and  siill  more 
seldom  does  it  lead  to  generalization  of  ilic  tuberculosis,  because 
it  generally  appears  in  jDcrsons  who  have  passed  their  childhood, 
and  besides  this,  because  the  bovine  bacillus  is  much  less  virulen*. 

Riehl'sand  Paltauf's  fourteen  cases  were  between  the  ages  of 
19  and  45  years;  the  cases  of  Meyse  .-ind  otln-rs  wf-rf  of  similnr 
ages. 

Exlensi\-e  tuberculous  ulceration  would  hardly  ensue  with 
older  persons  without  a  previous  superficial  wound. 

The  considerable  differences  which  the  skin  of  a  child  and  of 
an  adult  exhibit  with  regard  to  their  permeability  to  carbon  par- 
ticles or  tubercle  bacilli  are  the  same  also  for  other  bacteria ; 
it  would  lead  us  too  far  to  analyse  the  clinical  proofs  for  this. 

This  different  behaviour  of  the  skin  and  mucous  membrane 
of  a  child  and  that  of  an  adult  is,  apart  from  the  consideration  of 
immunity,  possibly  also  one  of  the  reasons  why  measles  and 
scarlet  fever,  as  well  as  some  of  the  other  infectious  diseases,  are 
more  easilv  communicated  to  children  than  to  adults,  a  belief 
which  is  deeply  rooted  among  the  lower  classes. 

It  appears  as  if  these  differences  obtain  also  in  the  lymph 
system  as  well  as  in  the  skin  and  mucous  membrane,  and  specially 
in  the  lymph  passages,  in  such  a  way  that  these  are  in  childhood 
more  easily  penetrated  and  broader  than  in  later  years.  Also  the 
thoracic  duct,  the  reservoir,  is  considered  to  be  wider  in  propor- 
tion in  childhood  (Benda).  On  this  point  strictlv  anatomical 
proofs  are  wanting  on  account  of  the  difficultv  of  such  researches 
(see  above),  but  it  is  generally  accepted  that  the  Ivmph-vessels 
in  childhood  are  broader.  Our  adoption  of  this  opinion  is  based 
on  the  fact  that  the  nutrition  of  the  tissues  is  speciallv  abundant 
in  the  child  on  account  of  the  continued  growth  during  the  vears 
of  development. 

It  was  Hueter  who  claimed  that  this  greater  width  had  to  do 
with  the  genesis  of  scrofulosis.  He  emphasized  the  difference 
between  the  dry  connective  tissue,  poor  in  cells,  of  the  adult,  and 
the  moist  connective  tissue,  rich  in  cells,  of  the  child,  and  attributed 
to  childhood  a  more  complete  plasmatic  circulation,  a  richer 
lymphatic  system  furnished  with  larger  passages.  Tli^  pastv, 
spongy  appearance  of  scrofulous  patients  shows  a  repletion  of  the 
connective  tissue  with  nutritive  fluid,  and  "  such  a  body  is  not 
unlike  a  sponge  filled  with  nutritive  fluid." 

Aviraguet  characterizes  scrofulosis  as  an  unusual  expansion 
of  the  lymphatic  system  (glands  and  vessels)  in  which  this  greater 


70  SCROFULOSIS 

extension  is  normal  in  early  years,  and  only  becomes  pathological 
when  it  is  long  continued  or  increases. 

Most,  to  whom  we  are  obliged  for  thorough  researches 
respecting  the  lymphatic  apparatus  in  children,  says,  "  The 
Ivmph  channels  themselves  are  relatively  wider  and  more 
branched  in  the  child,  also  the  glandular  elements  are  more 
numerous  and  lie  nearer  together  than  in  the  adult." 

A  greater  development  of  the  lymph  apparatus  has  also  been 
shown  experimentally  by  Ritter  to  depend  upon  the  larger 
quantitv  of  Ivmph  in  younger  persons. 

That  wider  channels  and  lymph  passages  facilitate  the  trans- 
port of  the  germs  from  the  surface  into  the  glands,  and  from  there 
farther  on  still,  is  a  matter  of  course. 

One  might  object  that  the  lymph  channels  which  are 
large  enough  to  give  passage  to  the  lymph  corpuscles  would  never 
present  difficulties  to  the  smaller  tubercle  bacilli. 

But  it  is  not  only  the  size  which  is  decisive.  The  tubercle 
bacillus  is  specifically  heavier  than  the  lymph  corpuscle,  as  the 
more  speedy  sinking  of  pus  proves,  a  factor  which  is  as  important 
in  the  microcosmos  as  in  the  large  world.  All  the  bacilli  are  not 
absorbed  by  the  lymph  cells ;  they  are  long,  and  easily  catch 
against  the  walls  of  the  passages,  like  the  trunk  of  a  tree  against 
the  banks  of  a  river,  whilst  the  round,  smooth  lymph  cells  slip  over 
them.  The  bacillus  has  a  firm,  unchangeable  shape,  whilst  the  active 
polymorphous  protoplasm  of  the  lymph  cells  winds  itself  through 
the  narrow  channels,  adapting  itself  to  their  lumen.  Small  differ- 
ences in  the  wadth  of  the  lymph  spaces  are  thus  not  without 
influence  with  regard  to  the  path  the  bacilli  take. 

The  different  course  of  tuberculous  disease  in  the  same  organ 
of  a  child  or  an  adult  is  to  be  explained  in  the  same  way  by  the 
greater  width  of  the  lymph  passages,  and  an  easier  power  of  con- 
veyance in  tuberculosis  of  the  lungs  in  children,  the  marked 
tendency  to  speedy  dispersal  over  the  whole  body  till  a  general 
miliary  tuberculosis  is  attained,  whilst  with  older  persons  the  lung 
process  only  spreads  very  slowly  (for  more  on  this  subject  see 
G.  Cornet,  "  Die  Tuberculose,"  second  edition,  vol.  ii,  p.  683). 
This  tendency  to  a  relatively  more  speedy  course  in  the  child  is 
marked  in  chronic  tuberculosis  of  the  glands  by  the  fact  that  whole 
groups  of  glands  are  attacked,  the  bones  suffer  at  the  same  time, 
and  even  miliary  tuberculosis  is  the  final  result. 

In  this  direction  children  behave  exactly  in  the  same  manner 
as  the  young  animals  used  in  our  experiments,  which  also  exhibit 
the  same  great  effort  to  propagate  the  tuberculous  process  in  the 
lymph  passages. 

Amongst   other   things,    the  circumstance   that  in   advanced 


CONCJiFTKJN    AND   CLASSll'lCATlOxN  OI'    SCKOl' l.I.OSIS  Jl 

phlliisis  we  very  olien  find  f(j(;i  iii  Mk'  lonsils,  \,\\\  in  atJults  the 
glands  belcjnging  lo  llieni  .'ir(-  sf^ldniii  .iII.m  k<(l  m  a  iDanner  worth 
mentioning,  whilst  in  eliildrcn  Miis  is  regularly  the  case,  proves 
the  difdcully  of  llu"  conveyance;  of  tin;  bacilli  from  ill'-  path  of 
entry  through  the  lyni|)li  channels  in  later  liic-. 

Also  tin;  (|uick  swelling  and  reduction  of  the  glands  from 
oilier  causes  in  childhood  may  be  connected  in  causative  relation 
with  the  breadth  of  the  lymph  channels  and  the  force  of  the  lymph- 
stream,  and  must  not  the  irritation,  which  universally  accompanies 
it,  be  put  down  to  this  cause? 

In  youth  we  meet  with  swellings  of  the  lymphatic  glands  cf 
the  neck  and  with  caries  of  the  teeth  in  an  extraordinary  number 
of  cases;  in  later  life  these  rarely  occur. 

In  other  tissues  this  same  difference  according  to  age  is 
established.  Korner  emphasizes  the  tendency  to  inflammation  of 
the  dental  periosteum,  in  caries  of  the  teeth,  and  more  especially 
in  the  milk  teeth,  because  these  have  "a  very  wide  pulp  cavity 
and  a  relatively  thin  coating  of  dentine,  so  carious  processes  very 
soon  affect  the  pulp  sympathetically,"  and  after  destroying  it  the 
dental  periosteum  is,  as  a  rule,  attacked  by  the  inflammation. 

But,  it  may  be  rejoined,  all  these  differences  lie  in  the  pre- 
disposition, and  the  power  of  reaction  of  the  glands  ;  but  the  single 
reference  to  the  homogeneous  and  passive  deposit  of  the  catbon 
particles  suffices  to  invalidate  this  objection. 

We  find  a  satisfactory  explanation  of  the  predominance  of 
scrofulosis  in  youth  (and  its  appearance  almost  without  exception 
in  youth)  in  diathesis  or  readiness  for  illness,  in  the  skin,  the 
mucous  membrane,  and  the  lymph  system,  dependent  on 
anatomical  circumstances,  that  is  to  say,  on  a  further  enhancing 
of  the  normal  increased  permeability  in  childhood,  of  the  skin, 
mucous  membrane,  and  lymph  passages,  a  condition  which 
may  be  designated  as  enhanced  infantilism,  or,  better  still, 
"  embrvonalism." 


(3)  DIFFERENT  PERMEABILITY  OF  SKIN  ACCORDING  TO  SEX. 

The  difference  of  the  frequency  of  scrofulosis  in  the  male  and 
female  sex  is  obvious.  We  have  noted  before  (see  p.  3)  that  the 
female  sex  is  attacked  more  frequently ;  girls  bring  a  far  larger 
contingent  than  boys,  especially  to  the  ranks  of  external  diseases. 
Among  the  116  cases  of  Lebert  combined  -with  skin  diseases 
44  were  males  and  72  females;  in  Rabl's  cases  of  scrofulous 
diseases  of  the  eves  the  number  of  girls  Avas  double  that  of  the 
bovs,  and  the  relative  percentage  was  23  girls  to  15  boys  (3  '.2). 
Satller  and   Guttman  state  that  the   frequency   of  scrofulosis  of 


72  SCROFULOSIS 

the  eves  is  tlDuhlv  as  greai  in  the  female  as  in  tlie  male  sex. 
Scrofulous  eaiarrli  oi  ihe  mucous  membranes  ]-)reponderates 
remarkably  in  the  female  sex.  The  only  exception,  the  severe 
bone  and  joint  affections  which  for  special  reasons  are  more 
frequent  in  the  male  sex  (49  per  cent,  boys  to  31  per  cent,  girls) 
does  not  make  any  considerable  change  in  the  total  proportion 
of  the  diseases,  which,  according  to  our  former  calculations, 
amounts  to  5  :C). 

In  opposition  to  this  more  frequent  scrofulosis  of  bones  and 
joints  in  boys,  in  vouth  tuberculosis  is  in  general  more  usual  in 
the  female  sex,  and,  as  an  explanation  of  this,  the  fact  has  been 
advanced  that  girls  are  at  home  much  more  than  boys,  and  there- 
fore more  exposed  to  opportunities  of  infection  (see  Cornet,  "  Die 
Tuberculose, "  second  edition,  p.  426). 

A  verv  natural  explanation  may  be  also  found  for  this 
according  to  our  conception  of  predisposition  to  scrofulosis. 

The  cause  of  the  preponderance  of  scrofulosis  in  females, 
and  especially  of  external  diseases,  lies  for  the  most  part  in  the 
manifestly  more  tender  skin  and  mucous  membrane,  a  sort  of 
infantilism,  as  is  shown  bv  the  more  frequent  prevalence  of 
lupus,  even  after  the  age  of  puberty,  and  continuing  even  ti'l 
later  years. 

The  fact  mentioned  bv  Korner,  and  also  well  known,  that  the 
female  sex  has  worse  teeth  than  the  male  sex,  mav  also  be  brought 
forward  as  an  example  of  the  more  tender  structure  of  the  super- 
ficial tissues  in  the  female,  as  we  have  before  remarked. 

The  ferriale  skin,  even  after  puberty,  more  resembles  that  of 
a  child  than  that  of  a  man,  and  stands  between  the  two. 

In  practical  life  the  leather  industry  has  long  known  such 
differences  in  the  sexes  in  the  skins  of  animals  and  makes  its 
choice  from  this  knowledge  according  to  the  technical  purpose 
for  which  they  are  required.  The  same  experience  of  the  human 
skin  was  gained  at  the  time  of  the  French  Revolution,  when  it 
was  worked  up  in  the  Meudon  factory;  female  skin  could  only 
be  used,  as  Hyrtl  informs  us,  for  belts  and  braces. 

(4)  INDIVIDUAL  DIFFERENCES. 

The  difference  of  permeability  which  skin  and  mucous  mem- 
branes exhibit  in  the  same  individual  (on  the  sole  of  the  foot  and 
palm  of  the  hand,  for  example,  the  skin  is  different  from  that  of 
the  inner  side  of  the  thigh)  show  us  without  doubt  that  these 
qualities  vary  even  in  individuals  of  the  same  age.  We  shall 
speak  later  of  the  conditions  of  this  difference  as  to  sex,  parentage, 
nourishment,  external  agents,  &c. 

Adults   are    only    attacked    by    scrofulosis    exceptionally;    in 


CONCKI'TKJN    AND   CLASSIFICATION   Ol-    SfH^fM-'CLOSIS  73 

them  individual  varialions  in  pftrmealjility--- tiic-  width  of  the 
slomala  and  lympli  channels -never  reced<;  sr)  far  frf)m  ilut  nt^rmal 
Ihal  Ihe  piolecl  ion  ;i.L;-,-iinsl  llie  dani^ers  <>i  daily  lite,  as  far  as 
scrofulosis  is  concerned,  is  insufiicient . 

Even  the  perineability  (A  the  covering  in  childhood  suffices 
to  a  certain  degree  in  individuals  for  the  ordinary  demands  of 
Hfe,  and  gives  ample  protection  against:  dangers  threatened  from 
without,  but  it  is  often  not  sufficient  when  the  agents  of  infection 
are  ninnerous  or  the  attacks  too  frequent. 

With  many  children  the  more  the  increased  permeability  of 
the  skin  and  width  of  the  lymph  glands  is  abnormally  increased, 
the  less  are  they  capable  of  withstanding  the  ordinary  dangers 
of  infection;  and  so  much  the  more  certainly,  as  a  natural  conse- 
quence, do  they  sufi:er  from  local  skin  or  gland  diseases  caused 
by  tubercle  or  other  bacteria.  In  this  we  may  see  one  of  the 
principal  causes  of  "  predisposition  to  scrofulosis."  The  force 
of  the  lymph  currents  varies  in  exact  proportion  to  the  width  of 
the  openings  of  the  lymph  channels. 

The  permeability  of  the  skin  and  the  mucous  membrane,  as 
well  as  the  width  of  the  lymph  passages,  do  not  always  run 
parallel  in  their  abnormality,  but  one  may  preponderate  at  one 
time  and  one  at  another,  and  so  stamp  the  disease  with  its  special 
mark. 

Virchow  has  called  attention  to  the  great  individual  variations 
due  to  the  size  and  number  of  the  lymphatics,  variations  which 
have  no  parallel  in  other  systems.  The  number  of  the  solitary 
glands  of  the  intestine,  and  the  mesenteric  and  bronchial  glands, 
the  size  of  Peyer's  patches,  the  tonsillar  glands,  neck  and  inguinal 
glands  vary  immensely.  As  he  remarks,  it  is  clear  that  here  we 
have  to  do  with  congenital  circumstances,  and  in  this  sense  we  also 
speak  of  a  lymphatic  constitution.  The  individual  variations  in 
number  and  structure  of  the  lymph  passages  naturally  cause  a 
difference  in  the  propagation  of  the  causative  agent  of  the  disease. 

The  view  of  scrofulous  diathesis  here  developed  as  a  local 
readiness  for  disease  confined  to  the  skin,  mucous  membranes, 
and  lymph  systems,  has  been  forced  upon  me  by  the  results  of 
numerous  experiments  on  animals,  and  is,  as  we  see,  confirmed 
by  abundant  clinical  facts  and  observations,  which  can  only  be 
explained  by  it. 

All  these  conceptions  are  only  relative,  and  it  would  be  m 
mistake  to  draw  a  hard  and  fast  line  and  to  say  in  one  case  it  -is 
not  possible  to  fall  ill  with  scrofulosis  and  in  another  that  it  is 
unavoidable. 

An  individual,  were  he  ever  so  much  predisposed  to  scrofu- 
losis, when  the  conditions  for  infection — the  intimate  contact  with 


74  SCROFULOSIS 

bacteria — are  wanting,  will  never  become  scrofulous;  such  a 
person  remains  latently  disposed.  On  the  other  hand,  a  child 
with  almost  no  predisposition  will  so  much  the  more  readily 
become  scrofulous  the  more  he  is  exposed  to  opportunities  for 
infection.  In  this  respect  a  certain  difference  is  brought  to  bear 
according  to  the  nature  of  the  cause  of  infection. 

We  must  strictly  individualize  not  only  in  the  case  of  the 
person  attacked,  but  also  as  to  the  causative  agent  of  the  disease. 

The  tubercle  bacilli  gain  an  entrance  into  the  body  much 
more  easily  than  other  bacteria  on  account  of  their  minuteness. 
But  by  reason  of  their  comparatively  slight  dissemination  outside 
the  body  (Cornet,  "  Die  Tuberculose,"  second  edition,  p.  99)  this 
entrance  is  not  so  often  repeated,  therefore  recurrences  are  more 
rare.  But  the  disease  caused  by  the  bacillus  has  another  symptom 
which  is  much  more  especially  marked  than  in  other  bacteria, 
namely,  persistency.  As  one  single  infection  is  sufficient,  by  being 
carried  to  the  glands  and  from  there  to  other  organs,  especially 
the  bones,  to  produce  the  whole  series  of  scrofulous  symptoms, 
so  the  tendency  does  not  play  so  important  a  part  in  producing 
the  clinical  phenomena  of  scrofulosis. 

Other  bacteria,  however,  demand  wider  paths  of  entrv  on 
account  of  their  size,  and  are  therefore  more  dependent  on  predis- 
position ;  the  symptoms,  especially  in  cases  of  reduced  virulence, 
are  not  so  obstinate  but  disappear  more  easily,  and  have  not  so 
great  a  tendency  to  disperse  over  the  nearest  glands  in  such  a  high 
degree,  or,  in  other  words,  the  glands  appear  to  have  greater 
powers  of  resisting  them.  One  infection  will  probably  not  suffice 
to  produce  the  phenomena  of  scrofulosis.  Only  after  repeated 
intrusion  (which  wnll  be  facilitated  by  their  greater  dispersal,  but, 
on  the  other  hand,  which  presupposes  a  greater  predisposition) 
will  the  phenomena  of  scrofulosis  with  the  repeated  recurrence 
and  the  multiple  external  foci  appear,  which,  owing  to  the  fully 
developed  lymph  system,  also  attain  to  a  high  degree  of  per- 
sistency.    Here  also  predisposition  has  great  weight. 

If  the  tendency  is  not  there,  in  spite  of  this,  one  tuberculous 
infection  can  cause  the  whole  complexus  of  symptoms  of 
scrofulosis  ;  but  the  picture  of  ordinary  non-tuberculous  scrofulosis, 
which  betrays  its  connection  less  by  its  pertinacity  than  by  its 
frequent  recurrences  and  its  sphere  of  action  will  hardly  ensue 
from  one  single  pyogenic  injection. 

We  differ  here  from  Hueter,  who  attributes  to  ever}^  scro- 
fulous person  an  increased  disposition;  this  conclusion  could  onlv 
have  been  attained  post  hoc. 


CHAPTER    III. 

GENESIS    OF    SCROFULOSIS. 


ScROFULOSis  arises  from  the  combined  effect  of  the  scrofulous 
tendency  with  bacteria.  Whence  come  the  different  bacteria 
which  we  find  in  the  scrofulous  changes?  Under  what  circum- 
stances do  they  reach  the  body  ?     How  does  the  infection  begin  ? 

1.  -CAUSATIVE   AGENT   OF   PUS. 

(a)  Appearance. 

The  origin  of  the  germs  of  infection  which  we  have  under 
consideration  is  different  according  to  their  species. 

The  ordinary  pus  cocci  and  streptococci  are  almost  ubiquitous 
in  closed  dwelling  rooms.  Wherever  we  leave  saucers  of  gela- 
tine about  some  pyogenous  colonies  will  be  sure  to  be  found 
developing  in  them. 

The  Bacillus  pyogenes  aureus  has  frequently  been  demon- 
strated on  the  human  skin,  in  the  cavity  of  the  mouth,  in  the 
saliva,  in  the  nose,  in  the  vaginal  secretion,  and  in  the  normal 
contents  of  the  intestine;  pus  cocci  have  also  been  found  in  the 
dust  from  factories  and  schools. 

It  is  more  rare  to  find  streptococci,  at  least  in  virulent  condi- 
tion, outside  the  body. 

Probably,  infection  depends  upon  living  in  closed  rooms,  but 
more  especially  when-  the  opportunity  is  given  of  contact  with 
persons  with  suppurating  processes  of  any  sort  and  when  such 
persons  do  not  sufficiently  guard  against  the  spread  of  the  virulent 
pus  cocci. 

But  these  pus  cocci  generally  possess  unequal  and  weak 
virulence,  so  that  the  danger  is  much  less  than  a  priori  appears, 
and  is  often  represented  to  be. 

Many  of  the  pus  bacteria  lose  their  virulence,  in  part  or  com- 
pletely, as  compared  with  tubercle  bacilli. 


76  SCROFULOSIS 

(b)   Mode   of   Infection. 

The  manner  of  infeclion  by  pus  cocci,  their  localization,  the 
spreading  of  the  process  to  the  next  lymph  glands,  is  the  same  in 
the  case  of  the  tubercle  bacillus,  and  I  must  refer  my  readers  lo 
the  next  page  for  further  particulars  on  the  subject. 

Numerous  experiments  prove  that  these  pus  bacteria  not  only 
introduce  themselves  into  the  skin  through  small  wounds,  but  even 
the  uninjured  cutis  of  adults  does  not  afford  sufficient  protection 
against  them  when  well  rubbed  in  ;  much  less  protection  is  afforded 
by  the  skin  and  mucous  membrane  of  a  child,  which  is  much  more 
tender,  and  still  less  with  that  of  a  child  who,  with  a  morbid  pre- 
disposition to  scrofulosis,  would  be  much  more  disposed  to  become 
infected. 

Garre  rubbed  cultures  of  pus  cocci  into  the  intact  skin  of  his 
forearm,  and  produced  a  good-sized  ulceration  at  the  place  of 
friction,  accompanied  by  swelling  of  the  lymphatic  glands.  Larr6 
and  Bockhardt  produced  typical  carbuncle,  boils,  and  pustules 
of  impetigo  bv  friction  with  cultures  of  staphylococcus.  Schimmel- 
busch  also  produced,  bv  rubl^ing  in  staphvlococcus,  pustules  in 
skin  that  was  proved  by  microscopical  examination  to  be  com- 
pletely uninjured. 

By  friction  with  Staphylococcus  pyogenes  aureus  and  S.  albus 
on  the  uninjured  skin  of  the  forearm,  Wasmuth  produced  flat 
red  patches,  and  by  more  vigorous  friction  blisters  containing 
pus.  Fie  also  infected  guinea-pigs  on  the  carefully  shaven  skin 
by  friction  with  anthrax,  and  confirmed  the  facts  that  the  un- 
injured human  skin  (X.B. — In  this  case  his  own)  is  more, per- 
meable than  that  of  animals.  This  permeability  of  the  skin  exists 
also  for  other  bacteria. 

The  permeability  of  the  mucous  membrane  of  the  lungs  for 
the  anthrax  bacillus  was  also  demoristrated  by  Buchner;  Roth 
succeeded  in  introducing  Ribbert's  bacillus  into  the  bodies  of 
animals  by  brushing  them  with  a  soft  brush  on  to  the  uninjured 
mucous  membrane  of  the  nose.  Infection  was  also  obtained  by 
rubbing  in  the  anthrax  bacilli  on  the  bare  skin  behind  the  ears  of 
guinea-pigs;  but  simply  placing  them  on  the  same  spot  without 
friction  produced  no  result;  he  found  that  fairly  strong  friction 
was  necessary. 

Machnoff  infected  animals  by  rubbing  anthrax  cultures  into 
the  shaven  skin  of  the  back,  using  only  light  pressure.  On 
examination  afterwards  no  injury  or  defect  of  the  skin  could  be 
discovered. 

Garre  considered  that  in  the  case  of  staphylococci  the  point 


GENESIS   OF  SCROFIJLOSIS  77 

of  entry  was  the  ducts  heading-  from  the  sebacecHis  and  sweat 
Hands.  Rolh  and  Wasnuilli  considered  that  the  anthrax  bacillus 
entered  by  the  same  route. 

All  these  experiments  made  on  men  were  on  adults,  wliich 
explains  the  fact,  the  cause  of  which  was  shown  above,  that  there 
was  no  superficial  spread  from  the  point  of  f-ntry,  and  that  the 
propagation  was  towards  the  glands. 

Tlie  frequency  of  swollen  glands  {e.g.,  in  the  neck),  without 
being  able  to  detect  the  place  of  entry  of  the  bacillus  which  gave 
rise  to  the  infection,  is  explained  by  the  greater  permeability  of  th.? 
skin  in  childhood.     For  clinical  examples  see  p.  85. 

According  to  Bender,  Bockhardt,  and  Gerlach,  eczema  can 
be  induced,  on  the  arm  being  irritated,  by  germ-free  filtrates  of 
staphylococci.  Neisser  and  Lipstein  do  not  confirm  this  toxic 
result,  as  the  same  effect  may  be  obtained  with  alkaline  bouillon 
C  Handb.  fiir  Path.  Mikr.,"'iii,  p.  130). 

II.— TUBERCLE    BACILLI. 

A.— HUMAN    TYPE. 

Occurrence. 

It  appears  that  shut-up  rooms  in  a  great  measure  account  for 
the  infection  by  tubercle  bacilli  of  the  human  type. 

Formerly  the  tubercle  bacillus  was  supposed  to  be  everywhere 
(ubiquitous),  but  could  not  be  discovered.  By  my  researches  it 
has  been  established  that,  as  a  rule,  it  is  only  found  in  numbers 
worth  mentioning  in  shut-up  rooms,  which  tuberculous  persons 
either  inhabit  constantly  or  occupy  for  a  time,  and  who  in- 
cautiously disperse  the  bacteria  contained  in  their  secretions.  At 
the  head  of  these  are  those  suffering  from  phthisis,  but  still 
patients  with  other  open  tuberculous  foci  can  also  afford  oppor- 
tunities for  infection. 

Mv  experiments  have  been  confirmed  both  positively  and 
negatively  by  Rembold,  especially  Schliephake,  v.  Kriiger, 
V.  Kastner,  Bollinger,  Kustermann,  Enderlen,  Prausnitz,  Petri, 
Martin  Kirchner,  Gotschlich,  Dudley  (see  also  Wagner,  Belli, 
Cacace,  Kunz). 

From  the  convincing  fact  that  tubercle  bacilli  are  not 
ubiquitous,  but  are  only  found  regularly  in  the  immediate  sur- 
roundings of  persons  suffering  from  phthisis  who  are  careless  in 
their  habits,  it  would  perhaps  be  well  not  always  to  speak  in 
general  terms  of  the  "  infinite  dispersal  of  the  bacilli  from  ^yhich 
no  one  can  escape." 


78  SCROFULOSIS 

rubercle  bacilli  are  a  source  of  clanger  to  children  threatened 
with  scrofulosis,  either  through  the  respiratory  passages  (infect- 
ing the  bronchial  glands),  or  by  entering  the  mouth  and  digestive 
organs  (infecting  liie  neck  and  mesenteric  glands),  either  mixed 
with  food,  or  by  dirty  lingers  and  such  means;  external  contact 
also  mav  infect  the  neck  glands,  or  other  glands  in  the  vicinity  of 
the  point  of  entry. 

Infection  mav  be  caused  by  material  in  liquid  or  dry  state. 

I  still  think  that  for  introduction  into  the  deeper  respiratory 
passages  the  dried  excreta  are  far  more  important  than  the  particles 
dispersed  by  coughing,  for  a  person  suffering  from  phthisis 
excretes  in  the  sputum  a  million  times  more  than  he,  in  most  cases, 
ejects  by  coughing ;  besides,  dried  sputum  has  much  greater 
vitaUty  than  finely  dispersed  spray,  and  so  forms  a  reserve  of 
infectious  material  during  a  longer  period. 

To  go  further  into  this  question  would  take  up  too  much  time. 
(I  refer  to  the  second  edition  of  my  "  Tuberculose,"  p.  in.) 

Sputum  or  other  excreta  containing  tubercle  bacilli,  when  in 
fluid  state,  appear  to  be  less  dangerous  for  the  spread  of  scrofu- 
losis, as  well  as  for  the  spread  of  tuberculosis  of  the  lungs,  as  the 
soiling  of  fingers  and  other  objects  is  more  easily  avoided. 

When  dry  the  bacilli  often  pulverize,  and  settle  here  and 
there  on  all  sorts  of  objects,  and  on  food,  without  betraying  their 
presence  to  the  eye,  and  when  not  inspired  are  deposited  on  un- 
covered parts  of  the  body,  such  as  the  nose  and  mouth,  and  pass 
on  to  the  regional  glands. 

As  scrofulosis  appears  at  an  early  age  infection  principally 
takes  place  at  home,  and  occurs  in  young  children,  most  fre- 
quentlv,  from  the  parents,  sisters  and  brothers,  grandparents,  and 
relations  who  dwell  with  them  or  frequently  visit  them,  or  to  whom 
the  children  are  sent  ("  pseudo-heredity  ") ;  in  better  class  families 
from  the  servants,  especially  nurses  and  wet  nurses;  in  poorer 
classes,  perhaps  from  boarders  or  lodgers. 

In  later  childhood  infection  may  arise  from  schoolfellows, 
playfellow's,  and  teachers.  And  when  they  visit  each  other,  from 
the  homes  of  their  friends  or  parents  and  relations.  Those  not 
biased  by  the  ideas  of  heredity  may  see  daily  in  their  practice 
clinical  proofs  of  such  infection. 

Disease  germs  may  be  carried  by  the  soles  of  the  shoes,  also 
by  flies,  but  such  causes  are  nothing  in  the  total  of  infections. 

Just  as  opportunities  for  infection  are  numerous,  so  are  also 
manner  and  place  of  infection.  With  a  view  to  ascertaining  the 
genesis  of  tuberculosis  and  scrofulosis,  I  endeavoured  to  study 
more  closely  these  conditions  and  the  path   of  the  infection   bv 


GKNIiSIS    Ol'    SCKOMLOSIS  79 

expcrimcnls.  My  own  (;x])(;rimcnl.s,  wliicli  w(::i"t;  iils<j  paiil)'  inafJ«,- 
for  anollicr  purpose,  go  back  for  llu;  gn-alf-r  part  to  tlip  years  1887- 
1892,  and  cover  about  4,oo(j  nniin.-ils. 

lixact  records  of  the  posi-morLcni  examinations  were  made  in 
about  2,000  of  these;  hiler,  as  the  fads  chscovered  repeated  tliem- 
selves  in  all  imporlaiit  points,  such  as  Ihe  sile  and  path  of  the 
infection,  (hcse  records  were  replaced  by  slir)ri  n()i(;s. 

EXPERIMENTAL. 

My  Experiments  on  Animals. ' 

I  have  been  enabled  to  graduate  the  experiments,  and  so  to 
imitate  and  follow,  step  by  step,  the  endless  variety  of  natural 
possibilities  for  infection  in  human  life  with  their  various 
effects ;  by  the  large  number  of  my  experiments  made  with  every 
variation  and  combination,  with  changed  amount  of  material  for 
infection  down  to  the  very  smallest  dose,  with  different  kind  of 
contact  from  hardest  friction  to  simple  touching,  with  the  most 
varied  localization  on  all  parts  of  the  skin  and  mucous  membranes, 
from  the  quite  uninjured  covering  to  that  in  which  the  continuity 
was  almost'  entirelv  destroyed,  and  witli  the  most  varied  time  of 
observation. 

(1)  SUBCUTANEOUS   INFECTION. 

In  subcutaneous  infection  on  one  side  of  the  hypogastrium 
(as  shown  by  autopsy  on  240  animals)  the  place  of  inoculation 
closes  at  first ;  after  a  few  days  it  breaks  open  and  forms  a  caseous 
suppurating  ulcer;  as  a  rule,  during  the  first  two  or  three  weeks, 
only  the  inguinal  glands  on  the  inoculated  side  become  infiltrated, 
then  caseated  and  softened ;  later  the  opposite  side  becomes 
attacked.  Generally  a  long  chain  of  glands,  gradually  becoming 
smaller,  spreads  itself  from  the  place  of  inoculation  upwards. 
The  peritoneum  remains  normal  usually,  or  is  slightly  injected; 
the  portal  glands,  and  esj3ecially  the  retroperitoneal  glands,  are 
caseated.  From  about  the  thirtieth  to  the  fortieth  day  the  spleen 
is  attacked  by  tuberculous  processes,  and  the  liver  from  about  the 
fortieth  day.  Only  about  the  fortieth  to  fiftieth  dav  there  appear 
in  the  lungs  and  bronchial  glands  isolated  tubercles  which  later 
become  numerous. 

In  animals  which  had  been  inoculated  between  the  toes  of 
the  hind  foot  a  small  scab  appeared  at  the  place  of  inoculation; 

^  I  take  this  method  of  procedure  from  my  book  on  Tuberculosis,  on 
account  of  the  importance  of  these  experiments  in  connection  with  scrofu- 
losis  and  tuberculosis. 


^O  SCROI-LLOSIS 

after  a  formight  a  s\vt)llen  gland  in  ilie  knee-jt)ini  of  ilic  same  side; 
after  three  to  four  weeks  there  occurred  swelling  of  the  inguinal 
glands,  and  from  about  the  seventh  week  miliary  tubercles  in  the 
spleen  and  liver,  while  the  lungs  remained  intact. 

In  six  animals  inoculated  between  the  toes  of  a  fore  limb  after 
three  weeks  the  ulnar  glands,  and  later  the  axillary  and  bronchi.ii 
glands,  were  found  caseated,  and  the  lungs  had  become  permeated 
here  and  there  with  isolated  tubercles ;  the  abdominal  organs  were 
only  attacked  in  the  case  of  animals  which  were  killed  later. 

If  the  tip  of  the  ear  were  inoculated  (as  was  done  in  four  cases) 
after  two  months,  a  chain  of  caseated  and  softened  glands  ran 
down  from  the  ear  of  the  inoculated  side  to  the  organs  of  the  chest ; 
later  the  lungs  were  found  to  be  highly  tuberculous,  but  the 
abdominal  organs  w'ere  only  affected  to  a  slight  degree. 

A  similar  result  was  obtained,  as  far  as  the  glands  and  other 
organs  were  concerned,  by  inoculation  (in  two  animals)  in  the 
inner  part  of  the  ear. 

(2)  CUTANEOUS  INOCULATION.^ 

Rubbing  with  sputum,  pure  cultures,  &c.  (eighteen  autopsies) 
on  the  skin  of  the  cheek,  nose,  and  forehead  were  followed  in  the 
places  inoculated  partly  by  ulcerations,  partly  by  lupoid  changes, 
in  many  places  by  a  scaliness  which  was  hardly  noticeable,  accord- 
ing as  the  injuries  which  had  preceded  the  inoculation  were  more 
or  less  superficial,  e.g.,  by  scratching  with  the  finger  nail.  But 
first  swelling  and  caseation  of  the  neck  and  bronchial  glands 
regularly  appeared  first  on  the  same  side  and  then  on  the  opposite 
side;  later  the  process  spread  to  the  lungs,  spleen,  and  liver. 
Rubbing  the  shaven  and  superficially  eroded  skin  of  the  bend  of 
shoulder  or  the  inner  side  of  the  thigh  had,  as  a  first  effect,  swelling 
of  the  axillary  or  inguinal  glands.  But  simply  placing  the  sputum 
or  culture  on  the  uninjured  skin  or  using  only  slight  friction  had  no 
further  consequence. 

Recent  years  have  brought  numerous  confirmations  of  my 
results. 

Cutaneous  injections,  mostly  by  rubbing  the  shaven  skin  with 
tuberculous  material  or  cultures,  were  tried  by  Cozzolino,  Man- 
fredi,  Frisco,  Courmont  and  Lesieur,  Bab^sand  Nouri,  C.  Frankel, 
Lewandowski  ;  sometimes  skin  tumours  or  verrucose  tubercles 
were  formed,  sometimes  the  skin  appeared  to  remain  intact;  but 

1  I  only  mention  here  such  animals  as  were  thoroughly  examined  and 
recorded ;  the  greater  number  of  others,  in  which  results  already  obtained 
were  only  confirmed,  remain  unmentioned. 


«      GENESIS    OF   SCK(;M;L0.SIS  Hi 

in  guinca-j^igs  and  (.alllc,  .-i.s  a  rule,  .svv(;lliiig  ol  the  n'-igliboiiring 
glands  occurred,  a,nd,  following  diis,  general  iul;<M-<,nlosi.s.  Jiab--^ 
and  C.  iM-ankel  have  [)rov(;d  by  means  of  a  microscope  I  he  presen<  <• 
of  luberclc  bacilli  in  Ihe  hair  follicles  afler  one  or  two  days. 

In  the  experiments  of  Tak(;ya  .md  Dold,  and  of  Julius  Meyer 
(who  used  sputum),  there  was  always  iub'|-(  ulosis  ,-ii  ih'-  i)la(  f  of 
injection. 

As  already  menlioned,  die  success  appears  to  depend  mostly 
on  the  greater  or  less  intensity  of  the  friction. 

Sometimes  the  scales  formed  thick  layers  and  <  rusis,  and  f;ven 
grew  to  considerable  excrescences  and  horns;  after  being  removed 
by  operation  considerable  loss  of  substance  resulted.  As  a  rule, 
animals  cutaneously  injected  succumb  much  later  than  those  sub- 
cutaneously  injected;  many  lived  for  a  year.  Changes  similar  to 
the  tuberculosis  verrucosa  cutis  appeared  in  rabbits. 

J.  Meyer  infers  the  great  importance  of  mixed  infection  for 
the  genesis  of  tuberculosis  of  the  skin  from  the  fact  that  by  rub- 
bing the  shaven  skin  of  the  abdomen  with  sputum  containing 
mixed  infections  he  obtained  a  much  more  extensive  development 
of  tuberculous  nodules  than  from  pure  material  (caseated  mesen- 
teric glands).  But  this  reasoning  is  not  conclusive,  for  in  the 
first  place  he  rubbed  in  many  more  bacilli  than  would  be  contained 
in  glands,  which  ordinarily  contain  but  few. 

If  French  investigators  especially  got  negative  results  from 
their  friction  experiments,  it  may  be  asked  if  these  authors  did  not 
experiment  with  tuberculosis  of  fowls,  which  was  formerly  much 
employed  in  French  laboratories.  Recently  Babes  succeeded  in 
inducing  infection  with  no  affection  of  the  skin  by  rubbing 
tubercle  bacilli  into  the  uninjured  skin.  (Breslauer  Naturf.-Vers. 
u.  Tub.-Kongr.,  1905,  Paris.) 

(3)  INFECTION  OF  THE  MUCOUS  MEMBRANES. 

Mucous  Membrane  of  the  Mouth. — In  other  animals  (of 
which  we  have  seven  autopsies)  sputum  was  introduced  into  the 
gums  with  a  blunt  or  a  sharp  instrument.  After  several  weeks  an 
ulcer  formed  on  the  spot,  but  sometimes,  after  eight  weeks,  there 
were  no  changes  whatever  to  be  noticed  at  the  place  of  injection. 
But  caseation  of  the  sub-mental,  sub-lingual,  and  neck  glands  in 
regular  sequence  set  in,  especially  on  the  injected  side ;  later,  some 
nodules  were  noticeable  in  the  lungs,  and  finalh*  in  the  spleen,  &c. ; 
the  bronchial  glands  were  hardly  at  all  caseated.  I  obtained 
similar  results  bv  rubbing  the  gums  (in  two  cases)  and  the  back 
of  the  pharynx  (two  cases)  and  of  the  tongue  (six  cases). 

In  these  cases  it  was  principallv  the  glands  of  the  neck  and 

6 


82  SCROFULOSIS 

ihe  iraclR-a  wliich  were  attacked,  and  showed  dilTuse  caseation 
before  the  bronchial  glands  were  implicated.  These,  in  the 
further  course  of  the  disease,  never  showed  such  extensive  changes 
as  resulted  from  inhalation.  From  six  to  ten  weeks  after  the 
infection  the  neck  glands  formed  large  softened  sweUings,  and 
then,  as  a  rule,  the  lungs  were  alYecled  sympathetically. 

Conjunctiva. — If  we  introduce  tubercle  bacilli  into  the  con- 
junctival sac  (as  was  done  in  twenty-four  cases),  with  or  without 
slight  friction,  after  two  to  four  weeks  small  ulcers  form  if  the  fric- 
tion has  been  preceded  by  slight  injury,  otherwise  only  injection 
and  thickening  of  the  conjunctixa  occur,  later  caseation  of  the  neck 
elands,  hrst  on  the  same  side  then  on  the  other  side,  and  caseation 
of  the  i)ronchial  glands,  followed  by  tuberculosis  of  the  lung  and 
of  the  abdominal  organs.  If  ilie  conjunciixa  through  the  exercise 
of  great  care  remained  uninjured,  in  many  cases  it  exhibited  no 
change,  and  then  the  nearest  glands  showed  the  hrst  tuberculous 
stages.  Once  no  infection  \\iiate\er  was  obiaincd,  pcrhajis 
l")ecause  the  infectixe  material  did  not  come  into  close  enough 
contact  with  the  mucous  membrane.  In  six  cases  of  corneal 
inoculation  ulcers  appeared  on  the  cornea;  the  state  of  the  glands 
was  the  same  as  in  conjuncti\al  infection. 

Ear. — Inoculation  in  the  inner  ear  (two  cases)  produced  after 
two  months  a  string  of  caseated  and  softened  glands  on  the 
injected  side  of  the  ear  down  to  the  organs  of  the  chest. 

Genitals. — If  the  penis  (twenty-one  cases)  were  rubbed  with 
sputum  or  pure  cultures,  provided  a  shght  wound  had  preceded  the 
friction,  an  extensive  ulceration  took  place  at  the  infected  place.  On 
rubbing,  with  no  visible  wound,  sometimes  the  penis  itself  showed 
no  change,  or  a  slight  ulcer  was  formed  after  about  two  to  three 
weeks;  as  in  the  other  cases,  a  swelling  occurred  on  the  infected 
side  and  later  on  both  sides,  with  caseation  of  the  inguinal  and  the 
retroperitoneal  glands ;  after  a  further  two  to  three  weeks  the  spleen 
and  liver  became  tuberculous,  and  it  was  only  after  a  few  months 
in  most  cases  that  tubercles  were  found  in  the  lungs.  One  animal 
lived  6^  months. 

Injections  in  the  urethra  (three  records)  gave  similar  results. 
v.  Baumgarten  caused  diffuse  tuberculosis  of  the  urethra,  followed 
by  general  tuberculosis,  by  injecting  tubercle  bacilli  into  the  un- 
injured urethra  of  a  male  rabbit,  w-hich  he  had  kept  for  several 
days  previously  without  food  or  water. 

By  rubbing  sputum  or  pure  culture  into  the  vagina  (in  thirteen 
cases)  by  means  of  a  sinooth  or  grooved  glass  rod — therefore 
without  preceding  injury,  or  only  slight  injurv — a  strong  milky 
discharge  was  caused,  also  a  typical  tul^erculous  development  in 


(iKNKSIS    OF   SCKf>M;i,OSIS  83 

the  vayin.'i  ^ind  iilcni.s,  vvliicli  dikc  (x  (  iini-d  m  llii-  bladder  also. 
But  ill  many  cases  die  \agina  r(;iTiaine(J  iinalier(,-d.  Alter  ;i  short 
time  sweliinj^-  and  caseation  of  llie  inguinal  glan(Js  ai}pearc(J  in  all 
(he  animals;  kilci'  caseation  ol  die  pcri-iiicriiic  gl-'inds  and  of  ihe 
glands  lying  near  the  \'ertebral  coknnii,  dicn  1  ubf-rcuU^sis  of  the 
spleen  and  li\er  occurred.  Injeclion  ol  piir<-  culture  into  the 
vagina  (of  which   I  lirivc  (luce  records)  produrcd  similar  results. 

fNi<i<:cTi()N  OF  Till-;  lNii:siiN.\L  Canal. —  In  feeding  experi- 
ments, some  of  which  were  made  before  my  own,  tubercle  bacilli 
introduce  themselves  through  (he  completely  intact  epithelium  of 
the  intestine  into  the  walls  of  the  intestinal  canal,  as  pro\ed  bv 
Wesener,  v.  Baumgarten,  Fischer,  Dobrokhmski,  Bollinger,  G. 
Cornet,  v.  Behring,  P.  Arloing  (in  dogs),  Uffenheimer,  Mac- 
fadyean  (in  monkevs),  Bartel,  &c.  Eitlier  they  develop  further 
here  and  form  tubercles  in  the  lymphatic  follicles,  especially  in 
the  ileum,  Ccccum  or  colon,  or  the\'  produce  ulcers  on  further 
absorption,  which  have  a  very  great  similarity'  in  their  changes 
to  those  of  human  intestinal  phthisis  (Fischer),  or  they  can  pass 
without  alteration  from  the  walls  of  the  intestine. to  the  mesenteric 
glands  and  there  develop  further.  Later  we  find  tubercles  in  the 
liver,  whilst  the  lungs  and  bronchial  glands  remain  unchanged, 
or  are  only  attacked  later  and  in  a  slight  degree  (see  also  the 
interesting  experiments  of  Nebelthaus). 

By  feeding  with  large  quantities  of  infectious  matter, 
especially  when  it  is  of  firm  consistence,  e.g.,  mixed  with  bread, 
now  and  again  the  neck  glands  became  affected,  clearly  bv  the 
taking  up  of  bacilli  from  the  mucous  membrane  of  the  tonsils. 
But  I  have  never  found  this  when  very  small  quantities  of  tubercle 
bacilli  were  mixed  with  the  food,  and  never  in  animals  (twentv-five 
in  number)  in  which  I  cautiously  introduced  the  infective  material 
directly  into  the  stomach  with  the  stomach  tube  (after  careful 
lavage)  so  as  to  exclude  contact  with  the  upper  digestive  organs. 

Infection  of  the  Respiratory  Organs. — With  slight  rub- 
bing of  the  tubercle  bacilli  into  the  mucous  membrane  of  the  nose 
(twelve  cases)  the  mucosa  remains  unchanged,  if  great  care  be  taken 
to  avoid  injury ;  in  other  cases  inflammation  takes  place,  and  after 
a  time  redness  and  ulceration. 

With  harder  friction  or  preceding  injury  ulceration  generally 
follows.  A  few  weeks  later  the  neck  glands  on  the  inoculated 
side,  and  then  those  of  the  other  side,  become  swollen  and 
caseated;  after  a  further  two  to  three  weeks  the  bronchial  glands 
become  tuberculous,  then  the  lungs,  and  onlv  at  a  later  stage  the 
spleen  and  liver. 

If  the  animals  (of  which  we  have  over  700  records)  inhale,. 


§4  SCROFLLOSIS 

no  matter  Avhether  sputum  or  culture,  whether  moist,  sprayed,  or 
naturally  dried  and  pulverized,  in  two  to  three  weeks  very  small 
greyish  white  spots  become  visibk-  in  ilie  lungs,  and  about  the  same 
time  the  bronchial  glands  become  enlarged  and  are  found  to  be 
inliltrated  with  a  medullary  substance.  The  tubercles  in  the  lungs 
enlarge,  and  should  the  animal  li\i'  long  enough,  now  antl  again 
cavities  are  formed,  the  bronchial  glands  develop  into  widespread 
masses  to  a  degree  attained  by  no  other  method  of  infection,  and 
later  caseate.  From  the  third  to  llu-  tifih  week  the  spleen  and 
liver  exhibit  signs  of  commencing  tuberculosis,  the  peritoneum 
and  omentum  remain  as  a  rule  unchanged,  the  neck  glands  are 
affected  sometimes,  but  mosllv  only  at  a  later  stage;  intratracheal 
injections  caused  large  caseous  foci  analogous  to  those  of  caseous 
pneumonia  in  the  kmgs.  The  rest  of  the  progress  was  the  same 
as  with  inhalation.  For  the  differences  in  the  arrangement  of  the 
experiment  with  sputum,  used  dry  or  wet,  as  well  as  other  details 
which  are  less  interesting  for  scrofulosis  (see  Cornet,  "  Die 
Tuberculosa,"  second  edition,  p.  135). 

If  we  use  extremely  small  quantities  of  sputum  for  inhalation 
the  lung  may  remain  free,  as  it  is  well  known  that  only  a  part 
enters  the  lungs,  and  after  from  four  to  six  weeks  only  slightly 
developed  tuberculosis  of  the  bronchial  gland  is  exhibited.  Jt 
appeared  to  me  this  was  specially  the  case  with  young  animals, 
but  on  this  point  my  records  do  not  always  give  exact  informa- 
tion, as  this  point  was  at  first  not  considered. 

(4)  INTRAPERITONEAL  INFECTION. 

After  injecting  tuberculous  material  into  the  peritoneal  cavity 
at  times  swelling  of  the  inguinal  glands  occurs  on  the  side 
inoculated,  but  this  is  clearly  when  the  material  for  infection 
enters  between  the  abdominal  skin  at  the  introduction  or  with- 
drawal of  the  syringe.  In  the  peritoneum  on  the  parietal  and 
visceral  layer,  especially  with  a  line  emulsion  of  tubercle  bacilli, 
numerous  small  tubercles  develop,  and  at  times  a  few  larger 
tubercles,  but  the  great  omentum  absorbs  the  bacilli  with  special 
regularity  and  to  a  great  extent,  and  the  tubercles  develop  in  the 
form  of  a  row  of  beads,  or  when  a  large  quantity  of  tubercle  bacilli 
are  absorbed  the  omentum  becomes  distended  in  the  form  of  a 
large  sausage  filled  with  a  caseous  mass.  A  serous  or  san- 
guineous discharge  is  present  from  time  to  time,  but  not  always. 
The  retroperitoneal  glands  are  affected  at  an  early  stage,  then  the 
spleen  and  liver.  At  times  the  advance  of  the  processes  can  be 
well  observed  from  the  peritoneal  side  of  the  diaphragm  to  the 
pleura    by    way    of    the    lymph    vessels    which    permeate    them. 


GENESIS    Ol'    SCKOl'ULOSIS  B5 

Tubcrcies  arc  foiiiicd  on   iIh-  di.-iplir.'igm.'Uic  plcuivi,   in   ilif  br^jii- 
chial  glands,  .'in<l  linnlly  in  I  lie  lun^^s. 

The  r(;|)orls  of  niosl  oIIhm'  authors  agrcf;  with  iho  abovf.-- 
m('nti()n(;d  dcsc.iipiion,  when  more  exact  details  are  given,  and 
the  hnman  tubercle  bacilb  and  noL  those  oi  fowls  are  employed 
(see  "  i'ariser  Kuhur,"  "  Die  TubcM-cuiose,"  second  edition,  [).  31) 
(for  results  whic  h  do  not  agree,  see  p.   100). 

(5)  INTRAVASCULAR  INFECTION. 

Infection  can  be  obtained  most  speedily  b)'  iniraxeiKju.-? 
injection,  e.g.,  into  the  jugular  vein  or  a  vein  in  the  ear.  Corre- 
sponding to  the  uniform  dispersal  of  the  material  for  infection  in 
the  blood-stream  we  find  tubercles  in  the  organs  of  the  chest  and 
abdomen,  in  the  lungs,  spleen,  and  liver  at  about  the  same  stage 
of  development ;  a  greater  number  is  often  found  in  the  lungs,  as 
this  organ  forms  the  first  filter  in  intravenous  injection. 

From  these  experiments  we  learn  this  most  important  fact 
concerning  scrofulosis,  that  it  is  always  those  glands  which  are 
attacked  first,  and  perhaps  only  those  which  lie  in  the  immediate 
vicinity  of  the  part  which  has  come  into  actual  contact  with  the 
tubercle  bacilli ;  it  is  indifferent  whether  an  injury  has  been  caused 
there  or  a  local  lesion  existed  previously.  Infection  w'ith  tubercle 
bacilli  is  a  direct  means  of  studying  the  anatomical  connection  of 
the  glands  with  their  tributary  areas.  I  must  lay  special  stress  on 
the  point  that  we  never  find  a  gland  tuberculous  when  it  is  at  a 
distance  from  the  place  of  infection  (although  perhaps  highly  pre- 
disposed) without  finding  the  intermediate  part  infected  with 
tubercle.  We  may  draw  from  this  tlie  corollarv  that  for  the 
primary  or  exclusive  disease  of  a  certain  gland  we  must  select 
the  tributary  areas  of  that  gland  as  the  place  of  infection  (see  also 
p.  88,  Law  of  Localization). 

CLINICAL   OBSERVATIONS. 

Are  we  justified  in  applying  the  same  chain  of  reasoning  to 
man  ?  Doubtless  we  are.  For  this  intimate  and  regular  connec- 
tion between  place  of  inoculation  and  disease  of  the  nearest 
gland  has  been  completely  established  bv  a  series  of  clinical 
observations. 

V.  Bergmann  as  early  as  1887  emphasized  the  fact  that  the 
successive  advance  of  the  infection  from  one  gland  to  the  next, 
from  one  group  to  another  in  the  direction  of  the  Ivmph  current 
is  most  clearly  marked  in  those  affections  of  the  glands  which  are 
connected  with  tuberculous  processes,   but  at  that  time  he  held 


86  SCROFLLOSIS 

thai  it  was  not  ci>ncUisi\  rl\-  pro\ecl  ihai  ihe  group  of  olaiuls 
which  la\  nearest  lo  the  intlamnKition  of  the  skin  was  always 
tlie  tirsi  lo  be  attacked. 

Other  chnical  e)l)ser\aiiiins  i>n  the  mosi  w  iiU'l_\"  ditterent 
regions  of  the  l)ody  accord  with  my  opinions  upon  tliis. 

Scalp. —  In  connection  with  a  tuberculous  infection  of  the 
scalp  bv  iul)t'rculous  uUers,  after  a  few  weeks  there  was  a  collec- 
tion of  glands  in  the  neck  (Dencke).  A\'ith  eczema  of  the  head, 
caseation  of  the  retromaxillary  glands  and  miliary  tuberculosis 
occurs  (Demme). 

Evi-:. — In  luberctilosis  of  ilie  i-onjuncti\a.  cornea,  and  of  the 
iris  (llaab),  it  is  generalU  ilu-  prc-auricular,  the  jaw  and  necic 
glands  which  are  luberculoush-  affected,  antl  only,  or  for  the  most 
part,  on  tlie  side  affected.  Thus  the  left  neck  glands  were  much 
swollen  in  the  case  of  tulierculous  ulceration  of  the  tarsal  con- 
junctiva, which  had  parilv  run  its  course,  in  the  left  eye  of  a 
bov  aged  14  (Sattler).  In  tul^erculosis  of  the  right  conjtmctiva  ilie 
pre-auricular  glands  were  onlv  swollen  on  the  right  side,  although 
it  was  evident  that  the  whole  of  tlie  l\mi~)h  gland  s\sleni  of  the 
neck  on  ])oth  sides  was  diseased  and  had  partly  suppurated  from 
some  other  infection  (Stolting).  Further,  swelling  of  auricular 
and  submaxillary  lymph  glands  on  the  side  which  was  diseased 
was  noted  by  Walb,  Haab,  &c.  (in  six  cases). 

Mouth  and  Pharynx. — According  to  the  researclies  of 
Krtickmann  and  Schlenker,  ^\ilh  a  tuberculous  infection  of  the 
tonsils  tuberculosis  of  the  neck  glands  will  follow  as  a  secondary 
consequence.  Sacaze  notes  that  in  tuberculous  inflammation  of 
the  tonsils  there  will  be  at  the  same  time  severe  swelling  of  the 
neck  glands.  Grawitz  notes  in  connection  with  inflammation  of 
the  tonsils  with  diphtheritic  membrane,  a  tuberculous  infection 
of  the  neck  glands.  I'ckermann  found  in  tuberculosis  of  the  left 
\'elum  palati  a  swollen  and  very  sensitive  gland  (in  a  woman 
aged  35)  under  the  left  angle  of  the  jaw  on  the  hinder  edge  of 
the  sternomastoid,  and  tinder  the  tip  of  the  mastoid  process. 
Wroblewski  often  found  in  fotirteen  cases  of  tuberculosis  of  the 
pharynx  (in  persons  from  22  to  59  vears  of  age)  considerable 
affection  of  the  lvm]5h  glands,  the  cervical  as  well  as  the  axillary, 
ulnar  and  inguinal  glands.  In  tubercuk)sis  of  the  tongue  (median 
region),  Poncet  and  Graser  found  swelling  of  the  submaxillary 
glands. 

In  a  child  which  previouslv  had  been  quite  healthy,  Steigen- 
berger  noted  that  after  it  had  been  suckled  four  weeks  bv  a 
nurse  who  was  phthisical,  it  developed  at  the  end  of  two  months 
a  hard  tuberculous  swelling,  the  size  of  a  hen's  ef!;g;,  in  the  neck 
glands  of  the  right  side  (containing  tubercle  bacilli).     Doutrele- 


GENESIS   OF  SCROFULOSIS  ^7 

pont  found  in  tuberculosis  of  llic  skin  .-umI  miKoir.  inrnibraiie  of 
the  right  cheek  lha,(  ilw  ii!_;lii  suhina  \ill;ir\  ;_;laii'ls  were  also 
swollen,  the  glands  on  ihc  Idi  side  w-ir  liai(ll\  enlarged;  laler 
tuberculosis  of  d)e  lungs  (»((nir<'d. 

Tkktii. — Odenlhal  found  in  ^4(1  rhildn-n  swelling  of  the 
submaxillary  glands  conse(|ueni  upon  denial  (arir-s.  Berten 
established  a  comjjlele  coincidence  noi  only  beiween  the  position 
of  the  caries,  but  also  between  ilie  iniensiiy  of  ihe  glandular 
swelling  and  the  caries  which  caused  ii.  I  loppe  also  established 
swelling  of  Ihe  maxillary  lymph  glands  as  an  extremely  frefpient 
consecjuent  symptom  of  caiies  of  die  leedi  ;  Siar*  k  noiiced  the 
same  slricllv  local  dependence  of  the  glandular  swelling  upon 
the  situation  of  (lie  carious  loolli  with  which  it  cf)rresponds,  not 
onl\'  on  the  side  of  the  body,  but  also  that  with  caries  of  the 
hinder  molars  the  glands  in  the  vicinity  of  the  angle  of  the  jaw 
are. swollen;  with  caries  of  the  canine  teeth  the  glands  farther 
forward  or  those  of  the  other  side  are  swollen.  Korner  proved 
in  1,646  children  the  correspondence  of  the  glandular  swelling 
with  the  affected  tooth,  both  as  to  position  and  degree  of  affection. 
Grawitz  remarked  tubercular  swelling  and  caseation  of  the  neck 
glands  on  the  same  side  in  consequence  of  caries  of  a  molar, 
and  tuberculosis  of  the  lungs  showing  itself  months  after  the 
first  appearance  of  the  swelling. 

Nose  and  Ear. — Tn  affections  of  the  nose  and  ear  we  see  the 
same  involvement  of  the  glands  on  that  particular  side,  A.  Jacobi 
refers  to  the  frequent  cure  of  scrofulous  inflammation  of  the 
cervical" glands  simply  by  treatment  of  the  nose.  Hang  found  in 
perichondritis  of  the  auricle  in  four  tuberculous  persons  that  the 
Ivmph  glands  of  that  part  were  tuberculously  intiltrated,  and  that 
in  a  chronic  middle  ear  catarrh  with  tuberculosis  of  the  mastoid 
process  a  small  gland  on  the  mastoid  process  was  similarly 
affected ;  in  primarv  central  tuberculosis  he  regards  the  affection 
of  these  glands  as  one  of  the  very  earliest  svmptoms.  According 
to  Ferreri,  the  salivarv  glands,  the  cervical  Ivmph  glands,  and  the 
joint  of  the  lower  jaw  are,  especiallv  in  childhood,  seldom  svm- 
pathetically  affected  in  diseased  processes  of  the  ears. 

Tn  tuberculosis  of  the  breast  the  axillary  glands  are,  as  a  rule, 
aft'ected  at  the  same  time  (Volkmann). 

Hoist  observed  tuberculous  swelling  of  the  axillary  glands 
consequent  upon  indolent  ulcers  of  the  finger  in  the  case  of  a  sick 
nurse  ;  Tcherning,  after  an  injury  to  the  hand  with  a  spittoon  ; 
Colling  and  Murray  observed  in  three  cases  pustular  formations 
with  consecutive  swelling  of  the  ulnar  and  axillarv  glands  after 
tattooing  on  the  arm  bv  a  person  suffering  from  phthisis;  Gerber, 
tuberculosis  of  the  axillarv  piands  four  months  after  tuberculous 


SIS  SCROl-LLOSIS 

infeclitMi  in  a  linger;  Leloir  noliced  in  connciiion  willi  lynipli- 
angieclaiic  lu|nis  tuberculo-scrofulous  swellings  in  ilu"  course  of 
the  thickened  lymphatic  vessels,  with  swellings  of  the  ulnar  and 
axillarv  glands,  and  later,  affection  of  the  lungs;  Koch,  caseation 
of  the  ulnar  glands  after  spina  bifula;  Schuchardt,  tuberculosis  of 
the  inguinal  glands  on  both  sides  consequent  upon  soft  chancre, 
tuberculosis  of  the  inguinal  and  pelvic  glands  after  ulcers  in  the 
•vagina;  Lindemann  (in  two  cases),  and  Lehmann  (in  ten  cases), 
tuberculous  ulceration  of  the  penis,  and  swelling  and  caseation 
with  suppuration  of  the  inguinal  glands  after  circumcision  by  a 
person  suffering  from  phthisis;  Hamilton,  tuberculosis  of  the 
inguinal  glands  consequent  upon  tuberculosis  of  the  lesiicle. 
Severe  swelling  of  the  femoral  glands  is  not  infrequently  found 
with  affections  of  the  foot  and  knee-joinls,  and  enlargement  of  ihe 
inguinal  glands  in  case^iting  processes  about  the  hip-joini  and  the 
acetabulum  (v.  Bergmann). 

For  further  details  I  refer  to  the  cliapter  on  "  Infection  of  the 
Glands,"  Cornet,  "  Die  Tuberculose,"  second  edition,  p.  353. 

These  clinical  experiences  in  man,  which  could  be  easily 
multiplied,  justify  us  in  assuming  that  the  results  of  our  experi- 
ments on  animals  would  be  the  same  in  man,  and  wherever  we 
come  across  a  primary  affection  of  the  glands  we  may  invariably 
seek  for  the  point  of  entrv  of  the  toxin  in  the  peripheral  region  of 
the  gland. 

In  practice  we  have  an  apparent  exception  to  this  rule.  Thus, 
f(^r  example,  a  pre-auricular  gland  was  swollen  as  the  result  of  an 
affection  of  the  eye,  and  at  the  same  time  the  bronchial  glands 
swelled,  without  the  cervical  glands  lying  between  showing  any 
changes.  But  in  such  cases  we  may  always  suspect  a  second 
independent  infection  in  the  lungs,  the  opportunity  for  vhich 
infection  was  given  at  the  same  time  and  under  the  same  con- 
ditions as  that  of  the  eye. 

LAW    OF    LOCALIZATION 

The  law  of  localization  has  been  drawn  up  hv  Cornel  as  I  he 
result  of  experiments  on  animals,  and  confirmed  b\-  clinical  experi- 
ence in  man. 

Tubercle  bacilli  which  have  entered  the  body  develop,  as  a 
rule,  in  the  organ  which  is  susceptible  for  that  special  virus,  imme- 
diately at  the  point  of  entry,  or  at  least  in  the  Ivmph  glands 
situated  nearest  (law  of  localization).  The  glands  act  as  a  filler, 
and  retain  the  bacillus  at  first.  Cohnheim  called  attention  lo  the 
connection  between  the  point  of  entry  and  the  localization  of  the 
tubercles. 


GKNKSiS    Oi'    .SCI<(jM.)-O.SI.S  89 

TIk;  furUicr  sprc-ul  111  iIm-  Ixidy  docs  iiol  l;ii:c  place  by  leaps 
.'ind  hoiiiitls,  bill  sicp  by  sicp,  I li<iflc »i':  ilw  |).-iili  of  entry  may 
almosl  alwavs  b(;  coikIim  led  vvidi  cci-l.-iinly  Irom  die  pathological 
condilion  as  indicalcd  in  di.'ii  0114.-111  in  whicli  tlic  disease  is  further 
developed  (for  Jiartcl's  objV(ii(jns,  see  p.  97).  This  guide  only 
becomes  unreliiible  when  ilic  processes  ar(;  rfjalively  old,  when 
several  organs  are  attticked  and  in  a  high  state  of  tuberciihius 
development,  the  paths  of  the  disease  being  thereby  obliterated. 
Tubercle  bacilli  can  penetrate  into  a  macroscopically  uninjured 
mucous  .membrane,  in  more  rare  instances  even  into  the  skin, 
especially  when  it  is  brought  into  intimntc  contact  by  friction,  as 
proved  by  niy  experiments  on  the  conjiindiva,  vagina,  mucous 
membrane  of  the  moiUh,  nose,  and  inlesiincs,  on  ihf  penis,  and 
cutis. 

It  does  not  necessariU-  follow  thai  llu-  tubercle  bacilli  must 
begin  to  develop  at  the  point  of  entry;  they  can  penetrate  the 
mucous  membrane,  and  in  exceptional  cases  even  the  skin,  without 
leaving  a  trace  behind ;  as  a  rule,  the  nearest  gland  is  never  passed 
over  without  tvpical  changes  taking  place,  be  they  ever  so  slight 

The  permeability  of  the  skin  and  mucous  membrane  for  the 
tubercle  bacilli,  first  confirmed  by  mv  experiments,  is  to  be  under- 
stood in  a  double  sense. 

The  bacilli  penetrate  and  establish  themselves  locally,  or  they 
mav  penetrate  and  be  located  in  the  nearest  glands  b}"  way  ni  the 
lymph  passages. 

This  permeability  of  the  skin  and  mucous  membrane  varies 
greatlv  according  to  age  and  sex  and  the  individual,  as  we  have 
explained  on  p.  6,^. 

This  enables  us  to  understand  that  after  infected  food  the 
mesenteric  glands  mav  become  tuberculous,  after  inhalation  the 
bronchial  glands,  and  after  infection  of  the  mouth  the  neck  glands 
may  become  tuberculous  without  the  lungs,  intestines,  or  mucous 
membrane  exhibiting  any  changes. 

This  laAv  of  localization  is  of  the  most  far-reaching  and  funda- 
mental importance  for  our  conception  of  the  genesis  of  tubercu- 
losis, its  mode  and  path  of  infection,  and  its  prophvlaxis.  which  is 
our  justification  for  its  thorough  discussion  in  this  place. 

OBJECTIONS  TO  THE  LAW  OF  LOCALIZATION. 

Influenced  by  the  theories  of  v.  Behring  on  the  enterogenous 
genesis  of  tuberculosis,  the  law  of  localization  was  subjected  for  a 
time  to  repeated  attacks. 

With  respect  to  the  permeability  of  the  mucous  membrane, 
v.  Baumgarten  and  his  pupils,  Takeya  and  Dold,   disputed  that 


90  SCROFULOSIS 

tubercle  bacilli  would  migrate  ihri>ugh  the  inlaci  mucous  mem- 
brane, and  maintained  there  were  always  microscopic  changes; 
de  Vechi  also  believes  the  normal  mucous  membrane  to  be  im- 
permeable; Klimenko  maintains  the  same,  but  adds  that  fre- 
cjuentlv  slight  injuries  are  present  which  allow  of  the  passage. 

Apart  from  older  experiments  (see  Cornet,  "  Die  Tubercu- 
lose,"  first  edition),  Ililgermann,  I'ffenheimer  and  Plate  have 
proved  microscopically  the  penetraiion  of  the  bacilli  through  the 
intact  mucous  membrane  (see  also  pp.  81-84). 

The  frequent  pathological  condition  of  tuberculosis  of  the 
bronchial  and  mesenteric  glands,  wiihoui  any  evidence  of  the 
slightest  injur\-  or  tuberculous  developments  in  the  mucous  mem- 
brane of  the  lung  or  intestine  respectively,  is  in  favour  of  the 
permeability  of  the  mucous  membrane. 

The  objection  that  perhaps  the  tuberculosis  of  such  glands 
mav  have  arisen  in  the  blood  passages  is  met  by  the  experiment 
on  completely  health}-  animals  in  which  we  can  induce  tuberculosis 
of  isolated  glands  where  we  \\ill,  in  any  gland  system,  in  the 
bronchial  or  mesenteric  glands,  without  injury  to  any  part  of  the 
mucous  membrane  either  by  inhalation  or  feeding.  As  such 
results  have  been  regularly  attained  by  myself  and  other  investi- 
gators in  hundreds  of  cases,  the  objection  that  the  animals 
may  have  been  diseased  and  the  mucous  membrane  not  intact 
(Hornemann)  is  unsound.  I  refer  further  to  the  extensive  experi- 
ments of  Uffenheimer,  ilie  discoveries  of  Max  Wolff,  of  Orth, 
and  L.  Rabinowitsch. 

I  have  proved  (p.  82)  the  permeability  of  the  mucous  mem- 
brane of  the  eye,  nose,  vagina,  and  Galbo  has  confirmed  the  same 
in  the  vaginal  mucous  membrane  of  guinea-pigs. 

Further,  in  the  above-mentioned  feeding  experiments, 
tubercle  bacilli  were  proved  (Barlel,  Kovacs,  Plate,  Hermann, 
&c.)  to  be  in  the  mesenteric  glands  even  after  a  few  hours  or 
days,  therefore  before  the  tubercle  bacilli  which  had  been 
swallowed  could  have  produced  changes  in  the  lining  of  the 
intestine. 

It  was  not  necessary  for  v.  Behring  to  base  his  theories  of 
the  entry  of  bacteria  on  Disse's  inconiinuity  of  the  mucous  mem- 
brane in  the  new-born  and  in  children  a  few  weeks  old,  as  long 
before  the  permeabilitv  had  been  experimentall\-  proxed  to  hold 
good  in  later  life  and  in  full  grown  animals. 

E\en  the  theory  of  the  genesis  of  tuberculosis  of  the  hing  bv 
inhalation  advanced  by  Tappeiner,  Koch,  and  others,  and  con- 
firmed by  me  on  more  than  i,o(X)  animals  (in  over  700  official 
recf)rds),  further  extended  and  considered  assured  bv  the  law  of 


GENESIS    Ol"   SCKOiLLOSIS  QI 

localization,  was  a<;ain  disputed  and  again  re-tested  on  all  sides. 
That  which  appeared  to  I  he  iin|)rejiidired  so  clear,  that  the  bacilli 
floating  in  the  air  would  Ix-  iii.spire<l  wilh  \\\<-  ;iir  and  so  ]><■  drawn 
down  the  free  and  open  air  passages  inio  the  lower  pari  of  ihe 
lungs,  and  so  arrive  in  I  he  minntesl  air  i)assages,  appeared  lo  he 
doubtful,  though  wilhonl  an\  e\  idem  reason;  it  was  niainiained 
that  the  bacilli  which  were  swallowed  in  inlialaiion  entered  the 
Stomach  and  intestines  and  ihe  niesenleric  glands,  and  from  there, 
without  leavin<r  a  trace  behind,  iiiio  ihe  ilioraci(  diu  I,  .'ind  ilience 
into  the  blood  and  the  right  side  of  the  heart  and  so  into  ilie  hings, 
iind  only  then  caused  the  |:>rimary  changes. 

Tliere  were  even  some,  such  as  Calnielie,  who  denied  ihat 
the  formation  of  anthracosis  of  the  lungs  was  aerogenic  and  arose 
from  direct  inspiration,  which  up  till  now  had  been  universally 
<icknowledged,  and  re\i\ed  the  assnm|)tion  which  had  been  dis- 
proved some  vears  before  by  Arnold,  that  the  carbon  particles 
which  were  inspired  were  tirst  swallowed,  and  tlien  migrated 
through  the  intestine  and  mesenteric  glands  in  the  way  already 
described,  leaving  no  trace  behintl,  and  only  by  an  indirect  route 
through  the  thoracic  duct  and  blood,  arrixed  at  their  definite  place 
of  deposit  in  the  lungs. 

But  the  experiments  of  Calmette's  pupils,  Vansteenburghe  and 
Grvsez,  which  were  to  have  demonstrated  the  truth  of  his  t]ieor\-, 
by  no  means  confirmed  it,  even  after  numerous  tests,  and  Avere  com- 
pletely disproved  by  renewed  experiments  bv  Schultze,  Aschoff, 
Passet,  Cohn,  Kuss  and  Lobstein,  Mironescu,  Remlinger, 
Tendeloo,  Beitzke,  and  Charles  ^Montgomery,  who  experimented 
with  carbon,  soot,  carmine,  prussian  blue,  &c.  Tendeloo  refers 
specially  to  the  fact  that  dust-pigment  has  ne\er  been  found  in  the 
human  mesenteric  glands,  either  in  adults  or  children,  but  that 
in  the  bronchial  glands  c^f  nearly  everv  person  dust-pigment  is 
to  be  found.  Why  should  the  bronchial  glands  retain  the  dust 
and  the  mesenteric  glands  not  ?     (See  also  Cobbet.) 

The  inhalation  experiments  instituted  by  Fvosch'  (GafTkv) 
Avith  sulphate  of  silver  or  ultramarine  and  emery  powder  showed 
that  even  with  animals  which  were  immediately  killed  (one  to 
tAvo  hours  after  inhalation)  the  inspired  substances  had  alreadv 
penetrated  deeply  into  the  lungs. 

It  is  the  same  with  tubercle  bacilli.  They,  too,  enter  directly 
into  the  lungs,  and  not  by  the  indirect  way  of  ingestion,  already 
described.  The  recent  experiments  of  Bartel  and  Neumann,  as 
well  as  Heymann,  prove  this.  They  killed  the  animals  experi- 
mented on  immediately,  or  very  soon  (live  to  ten  minutes)  after 
the  inhalation   of  tubercle  bacilli   which   had  already   penetrated 


92  SCROFLLOSIS 

inu>  lilt-  ini.nuU'.si  bronchial  luhcs;  llryinanii  also  cicnionstraied 
them  bv  excision  in  alveolar  and  epithelial  cells.  After  inhalation 
of  a  c|uaniitv  of  bacilli  they  were  found  imniedialely  in  the 
bronchial  glands,  btit  when  only  a  small  quaniily  were  inhaled 
thev  were  o.nlv  found  to  be  present  after  three  days.  Ballin's 
experiments  with  aspergillus  spores  led  to  the  same  results. 

This  penetration  of  the  bacilli  into  the  minutest  air  passages 
was  again  pro\ed,  and  has  become  e\idenl  in  L'almette's  and 
Guerin's  own  experiments;  their  further  objection  that  one  cannot 
be  sure  that  the  bacilli  they  found  were  not  induced  by  tuber- 
culosis needs  no  further  discussion. 

Now  it  was  endeavoured  to  prove  b}-  other  means  that  the 
bacilli  ingested  with  the  food  passed  through  the  intestinal  and 
mesenteric  glands  \\iihout  j^roeliicing  any  changes,  then  arrived 
in  the  lungs  bv  wav  of  the  thoracic  duct  and  the  right  heart,  there 
producing  the  primary  foci. 

Calmette,  who  defended  this  opinion,  believed  that  he  and 
Guerin  had  demonstrated  it,  because  he  had  observed  in  those 
animals  into  which  he  had  introduced  bovine  bacilli  by  means 
of  the  oesophageal  tube,  besides  intestinal  tuberculosis,  severe 
tuberculosis  of  the  lungs,  the  bronchial  and  mesenteric  glands. 
But  just  the  fact  that  the  other  organs — liver,  spleen,  and  kidney 
— which  also  take  part  in  the  circulation  remained  free  is  a  clear 
proof  that  we  are  not  here  concerned  with  a  ha^matogenous 
infection  of  the  lungs,  btit  evidently  that  during  the  withdrawal 
of  the  tube,  which  by  incautious  handling  might  easily  happen, 
infectious  matter  entered  the  trachea,  and  caused  the  infection  of 
the  lungs. 

But  Calmette's  young  goats,  which  he  allowed  to  be  suckled 
in  a  natural  manner  by  a  mother  sufifering  from  tuberculosis  of 
the  udder,  only  developed  intestinal  tuberculosis  (see  also 
Calmette,  Guerin,  Delarde).  Beitzke  raised  the  objection  against 
Calmette's  and  Guerin's  further  ingestion  experiments,  as  well 
as  those  of  de  Haan,  as  far  as  adult  ruminants  were  concerned  bv 
eructation  of  the  bacilli  w^hich  had  been  introduced,  and  aspiration 
mav  have  induced  infection  of  the  lunps. 

To  eliminate  the  source  of  error  that  in  feeding  by  the  tube 
a  part  of  the  bacilli  might  enter  the  lungs  on  its  withdrawal, 
Schlossmann  and  Engel  laparotomized  young  animals,  injected 
bacilli  into  the  stomach,  and  sewed  up  the  place  of  injection  ;  when 
six  hours  later  they  excised  the  lungs,  and  by  inoculating  them 
induced  tuberciilosis,  they  thought  they  had  proved  their  theory 
that  the  bacilli  might  migrate  through  the  regional  glands  with- 
out leaving  a  trace  behind.     But  the  after-test  brought  to  light 


(iKNicsis  OF  .s(;k(jm;i,(>sis  93 

tlie  en-or  of  llic  (■xpcrimcni .  Si  i;is.siicr  pointed  oiii  ili;ii  ilic  very 
fcict  of  sewing  lip  llif  lliin  w.'ill  (»l  llic  .stoiii.-icli  ml  r()(lii(,<-<J  g<;rms 
into  the  peritoneum,  wliilsl  in  a  simil.-ir  cxpcrinKMil,  wiilioiii 
sewing  up,  even  willi  large  doses  of  2  grm.  <A  i  iilxii  le  culture, 
no  bacilli  came  immediately  into  the  blood;  fiirili»i-,  in  animals 
which  were  allowed  to  live  longer,  after  three  monilis  the  mesen- 
teric glands,  and  parliallv  iIk'  axillary  glands,  were  tuberculous, 
while  the  bronchial  glands  were  spared  in  .-i  niosl  remarkable 
manner. 

This  also  r(^futes  at  I  lie  same  time  the  experiments  of  Kavenel 
and  Reicliel,  who  had  operated  in  I  he  same  manner  as  Schloss- 
mann and  Engel. 

The  experiments  of  Oberwarth  and  L.  Rabinow  its(  h  are 
easily  exposed  to  error  by  the  complicated  arrangements  (inducing 
a  fistula  into  the  stomach),  and  are  also  not  decisive  on  account 
of  the  enormous  doses.  Besides  which,  Uffenheimer  showed  that 
bacilli  introduced  by  clyster  rise  upwards  in  an  antiperistaltic 
manner,  and  even  reach  the  lungs.  The  fact  that  tuberculosis  by 
aspiration  in  similar  experiments  is  difficult  to  avoid,  and  cannot 
be  entirely  excluded,  was  confirmed  by  Dieterlen. 

Such  experiments  are  therefore  by  no  means  determinative 
on  account  of  the  errors  which  creep  in.  Up  till  now  no  single 
experiment  proves  without  objection  that  tubercle  bacilli, 
especially  in  full-grown  animals,  can  penetrate  the  intestinal  and 
mesenteric  glands  without  leaving  a  trace,  without  leaving  at  least 
visible  changes  in  the  glands ;  not  to  mention  the  conclusion  that 
human  tuberculosis  of  the  lungs  in  adults  is  most  frequently  of 
intestinal  origin,  a  conclusion  which  has  no  trace  of  justification. 
They  now  endeavoured  to  demonstrate  the  penetration  of  ingested 
bacilli  into  the  blood,  liver,  and  spleen. 

Picker  found  in  young  sucking  animals  germs  ingested  with 
the  food  already  in  the  blood  during  the  time  of  digestion,  and 
in  older  animals  when  they  were  starving  or  working  on  the  tread- 
mill, but  the  results  were  not  uniform.  Kovacs,  Plate,  Reichen- 
bach  and  Boch,  Calmette,  Guerin  and  Breton,  Bisanti  and 
Panisset  fed  animals  with  matter  containing  tubercle  bacilli ;  Orth 
and  L.  Rabinowitsch  introduced  it  by  means  of  a  clvster,  and 
declared  that  they  found  tubercle  bacilli  in  the  liver,  blood,  and 
spleen  in  some  animals  after  several  hours,  or  several  davs, 
respectively. 

.  But  these  results  are  not  free  from  doubt ;  first  of  all,  with 
similar  arrangements,  similar  results  were  not  alwavs  obtained. 
Thus  Orth  and  L.  Rabinowitsch  in  forty-two  experiments  onlv 
found  bacilli  in  the  blood  five  times. 


94  SCROFLLOSIS 

Slrassner,  in  his  experinieius,  never  found  bacilli  in  the  blood 
ten  hours  afier  ingestion,  and  referred  to  similar  negative  results 
with  Hariel  and  I'ffenheimer. 

To  thoroughlv  criticize  each  single  series  of  experiments 
would  lead  us  here  too  far.  The  strenuous  and  painstaking  \v(jrlv 
of  Kovdcs  may  serve  as  an  example. 

Kovacs  fed  new-born  guinea-pigs  with  a  culture  of  tubercle 
bacilli;  after  several  hours  he  killed  them,  and  microscopically 
exaniini'd  ihc  hlooii,  li\er,  spleen,  kidneys,  lungs,  marrow,  die 
portal  and  retroperitoneal  glands,  and  inoculated  portions  into 
guinea-pigs.  Once  he  "  succeeded  "  in  iinding,  several  hours 
after  ingestion,  a  few  tubercle  bacilli  in  a  portal  gland,  in  a  streak 
preparation  ;  all  other  experiments  had  negative  results. 

Then  he  found  bacilli  in  a  portal  gland  once  among  eight 
voung  gtiinea-pigs  eight  hotirs  after  feeding,  and  once  in  a 
cervical  and  axillary  gland  three  days  later,  when  two  and  a  few 
bacilli  respectively  were  found.  Twelve  other  animals  only 
showed  the  recognized  condition  in  the  cervical  and  mesenteric 
Sflands  after  ingestion.  Animals  which  were  fed  with  tubercle 
bacilli  in  tine  emulsion  by  means  of  a  lube  developed  tuberculosis, 
once  in  the  liver  seven  hours  after  feeding;  in  the  spleen  twenty- 
four  hours  after  feeding;  in  the  spleen  and  blood  two  days;  and 
in  the  liver  ten  days  after  feeding. 

One  other  case  of  tuberculous  spleen  is  rejected  as  clearly 
older;  tuberculosis  of  the  lungs  was  present. 

The  positive  conditions  in  the  bronchial  glands  prove  nothing, 
for  with  aptificial  feeding,  as  with  ordinary  taking  of  food,  there 
can  easily,  according  to  Kovacs'  own  statement  {loc.  cit.,  p.  297), 
be  some  of  the  ingested  bacilli  forced  into  the  lower  air  passages 
b\-  the  current  of  air. 

In  these  experiments  only  the  most  fa\oufable  conditions  are 
sought  out,  new-born  or  young  animals  are  utilized,  and  yet,  in 
spite  of  this,  numerous  negative  results  are  opposed  to  solitary 
positive  results.  This  alone  makes  their  evidence  inconclusive, 
besides  which,  in  solitary  cases,  one  must  always  reckon  with 
errors  in  the  experiment,  unintentional  injur\-  to  the  vessels, 
infection  of  the  blood,  &c. 

Therefore,  we  can  b\'  no  means  agree  with  Kovacs  when  he 
says  that  these  results  "  represent  the  gravest  harm  and  a  contra- 
diction to  the  accuracy  of  the  law  of  localization,  and  force  us  to 
other  opinions  respecting  the  path  of  infection,  mode  of  dispersal, 
and  localization  of  ingestion  tuberculosis. 

Rabbits  injected  with  human  bacilli  showed  after  three  to  five 
weeks   tubercle    in    the    lungs   and    kidney    without    macroscopic 


GliNIiSIS    Ol-    SCKC^l'LLOSIS  95 

disc.-isc  ol'  llic  lun^''.s.  Tliis  is  ;i  [x-niliarity  of  tl)c  rabljil,  estab- 
hlisln-d  bv  (  )('lilc(l<('r,  \\lii(li  in.-iy  be  explainr-d  by  the  Ifss 
vii'iilcncc  ol  ilic  liimi,-ii)  b.-icilb  lor  lliis  class  of  animal,  by  which 
the  bacilli  can  i)as.s  more  easily  iIii(Mil(Ii  iIic  ^dands  without 
seninq-  up  reaction.  We  also  find  in  lais,  when  inoculated  with 
liiunan  bacilli — perhaps  from  die  same  cause  dial  diere  is  a 
speedy  passing  of  the  bacilli  inl(j  die  blood,  but  nf)  tuberculosis. 
These  observations  ha\'e  nothing  to  do  with  the  law  of  localization 
of  a  virulent  infection  in  man. 

In  all  cases  a  premature  penetration  of  the  bacilli  into  the 
blood-stream,  if  it  take  place,  only  appears  under  cjuite  special 
circumstances,  (hat  is,  1)\'  the  use  of  enormmis  doses  of  bacilli, 
which  the  fdtering  power  of  the  glands  is  not  capable  of  resist- 
ing, or  in  certain  classes  of  animals  (rabbits),  and  at  certain  ages 
(in  sucking  or  young  animals),  or  with  a  type  of  bacillus  which 
is  foreign  to  the  species,  but  it  takes  place  neither  regularly  nor 
frequently,  therefore  it  is  quite  out  of  the  question  that  this  state 
of  things  should  be  of  practical  importance  for  htmian  pathology. 

The  whole  of  our  experimental  experiences  are  against  a 
speedy  migration  of  the  bacillus  into  the  blood,  for,  according  as 
we  infect  animals  b\'  feeding  or  inhalation,  subcutaneously,  intra- 
peritoneally,  or  intra\'enously,  we  obtain  in  from  three  to  four 
weeks  phenomena  which  are  totally  distinct  and  easy  to  differen- 
tiate before  their  characteristics  have  been  effaced,  and  this  occurs 
not  only  now  and  again,  as  I  have  observed  it  in  about  4.000 
animals,  Weleminsky  in  about  3.000,  and  all  other  authors  taken 
together  perhaps  as  often  or  oftener,  but  with  constant  regularity. 
Thus  in  many  hundreds  of  feeding  experiments  made  bv  the  most 
various  investigators  and  corresponding  to  natural  conditions 
(which  is  best  obtained  by  well-moistened  food  that  does  not 
pulverize  or  scatter),  after  three  to  four  weeks  nothing  appears,  as 
a  rule,  except  isolated  tuberculosis  of  the  mesenteric  glands,  intes- 
tinal glands,  and  eventually  of  the  neck  glands. 

This  would  not  be  comprehensible  if  the  bacilli  entered 
the  blood  a  few  hours  or  days  after  such  experiments,  for,  as 
Kovacs  says,  in  this  their  fate  can  onlv  be  the  same  as  that  which 
is  observed  after  direct  injection  into  the  blood-stream,  that  is, 
they  Avould  be  deposited  and  develop  in  certain  organs,  such  as 
the  lungs,  spleen,  and  liver.  Then  after  three  to  five  weeks  such 
tubercles  here  and  there  must  appear  to  be  caused  bv  strav  bacilli, 
but  we  only  find  them  very  occasionally,  a  proof  of  the  saving, 
"  Nulla  regula  sine  exceptione." 

Now  some  authors  defend  themselves  with  the  assumption 
that  the  few  bacilli  which  have  come  in  this  wav  directly  into  the 


96  SCROI-L  LOSIS 

blood  are  destroyed  by  iis  bacicricidal  power.  Good  I  But  in 
the  lirst  place  this  assumption  is  for  the  present  only  a  hypothesis 
of  which  there  is  no  strict  proof ;  on  the  contrary,  experience 
shows  that  it  is  just  in  infection  of  the  blood,  in  intravenous 
injections  that  the  least  quantity  of  virulent  bacilli  suflices  to 
cause  the  most  extensive  development  of  tuberculosis.  Secondly, 
if  the  bacilli  were  destroyed,  then  their  im])orlance,  which  has 
been  constructed  with  so  much  labour,  is  again  lessened.  St)  up 
up  till  now  we  have  onlv  hvpothesis  and  a  few  exixM-imcnts  which 
mav  be  construed  any  way. 

There  are  those  who  have  not  studied  these  questions,  but 
who  read  the  conclusions  on  both  sides  and  consider  them  of 
equal  value,  although  the  one  theory  is  based  on  a  few  positive 
observations,  and  the  other  supported  by  experiments  on  many 
thousands  of  animals  and  painstaking  researches  extending  over 
man\-  vears,  whi(-h,  if  they  are  to  be  refuted,  may  at  least  demand 
that  they  shall  be  refuted  with  equal  tlioroughness. 

The  whole  of  our  experience  of  morbid  anatomy  in  man  con- 
tradicts that  positive  discovery;  the  numerous  isolated  cases  of 
tuberculosis  of  the  intestinal  and  mesenteric  glands,  tlie  still  more 
numerous  cases  of  genuine  isolated  tu]:)erculosis  of  the  bronchial 
glands,  the  isolated  tuberculous  neck  glands  in  those  in  whom 
throughout  the  rest  of  the  body  no  trace  of  tuberculosis  is  to 
be  found,  must  suffice.  I  refer  my  readers  to  the  reports  of  our 
pathologists,  Benda,  Tendeloo,   Ribbert,  &c. 

In  these  cases  where  have  the  bacilli  gone  w^hich  were  said 
to  hiive  escaped  from  the  lymph  passages  and  entered  into  the 
blood  ?  as  we  can  find  tubercles  nowhere  else. 

These  isolated  tuberculous  individuals  would  be  much  more 
numerous  if  man  were  not  so  frequently  exposed  to  double 
infection,  for  when  a  tuberculous  person  has  the  opportunity  of 
inhaling  dust  in  the  vicinity  of  a  consumptive  patient  with  un- 
cleanly habits,  the  dust  containing  bacilli  may  easily  settle  on  his 
food,  so  that  sooner  or  later  a  tuberculous  focus  may  be  set  up 
in  the  intestinal,  mesenteric,  or  neck  glands,  or,  on  the  other 
hand,  he  may  inhale  bacilli  in  addition  to  his  tuberculosis  of  the 
intestine. 

It  is  just  this  dual  or  manifold  infection  of  different  organs 
from  the  outside  which  is  the  principal  cause  of  illusive  conclu- 
sions about  the  mode  of  dispersal  of  the  bacillus  in  the  body, 
unless  the  question  has  been  studied  by  experiments  on  animals. 

But  we  often  meet  with  such  concurrent  infections,  even  in 
experiments  on  animals,  where  we  have  the  conditions  more  in 
our  grasp,  and  often  they  cannot  entirely  be  avoided,  especially 
when  we  neglect  certain  precautionary  measures. 


(ilONKSlS    Ol'    SCKOIII.OSIS  97 

An  example  of  iliis  may  be  found  in  Kovacs',  liarK-l's,  &c., 
animals,  which  dcNcloped  simuhaneously  luhcnulosis  of  the  neck 
and  mesenteric  glands,  or  lul)erculosis  of  the  neck,  broiu  hi.-ii, 
and  mesenteric  glands,  and  of  the  lungs. 

Such  dual  or  parallel  infcclion,  lo  wliicli,  unless  I  ni,-il<e  -i 
mistake,  Ribberl,  Lubarscli,  .-md  llarbil/.  ha\»-  already  alluded, 
play  a  grealer  pari,  even  in  one  and  the  same  (^rgan,  than  one 
commonly  sup|)oses,  for  even  in  the;  lungs  and  intestines  not 
nearly  all  (lie  foci  are  to  be  ascribed  lo  ilie  llrst  infection  and  its 
spreatling.  In  conlradiction  to  Meissen,  &c.,  who  tried  to 
ridicule  this  point  of  view,  I  have  for  many  years  repeatedly 
pointed  out  that  il  is  just  the  i)hlhisical  patients  who  must  guard 
against  continued  opportunities  for  further  infection  of  the  lungs, 
which,  as  a  rule,  establishes  itself  in  a  part  which  has  hitherto  been 
healthy. 

To  return  to  those  experiments  (p.  93)  which  gave  rise  to 
this  discussion  :  they  have  demonstrated — in  contradiction  to  the 
statement  of  Calmette,  Schlossmann,  &c.,  that  the  bacilli  migrated 
through  the  mesenteric  gland,  leaving  no  trace — that  in  animals 
which  were  allowed  to  live  tuberculous  foci  were  regularly  found 
in  the  nearest  gland  to  the  point  of  entry,  the  mesenteric  gland 
(see  Uffenheimer,  Kovacs,  Orth,  L.  Rabinowitsch),  thus  they 
confirmed  the  law  of  localization  in  this  respect,  according  to 
which  the  bacilli  are  at  first  retained  in  the  nearest  gland. 

Bartel's  Latent  Foci. — A  further  objection  to  the  law  of 
localization  has  been  made  by  Bartel,  which  we  must  discuss  the 
more,  not  only  because  he  has  distinguished  himself  by  his  exact 
researches,  but  because  his  work  plays  a  great  part  in  literary 
discussions.  Bartel  demonstrated  the  presence  of  living  bacilli 
in  the  lymphatic  tissue,  the  tonsils,  the  lymph  glands  of  the  neck, 
and  mesentery  of  an  animal  on  which  he  experimented  a  hundred 
and  four  days  after  ingestion,  in  w-hich,  on  being  microscopically 
examined,  "up  to  that  time  no  specific  changes  "  were  to  be 
observed,  and  the  bacilli  were  to  be  put  down  to  the  infection  which 
took  place  a  hundred  and  four  days  previously.  Bartel  con- 
cludes from  this  a  latent  stage  up  to  a  hundred  and  four  days. 

These  and  similar  observations  made  under  the  same  circum- 
stances in  shorter  times  after  feeding  gave  rise  (i)  to  the  opinion 
that  clinically  an  organ  may  very  often  not  offer  any  characteristic 
symptom  of  tuberculous  infection,  and  yet  the  opportunities  for 
infection  are  to  hand  and  have  been  demonstrated  (such  animals 
becoming  thin,  with  arrested  growth,  and  occasional  swelling  of 
the  glands),  and  must  lead  one  to  suspect  it;  (2)  to  the  opinion 
that  with   tuberculous  injection,    besides  the  stage   with   evident 

7 


g8  st'Roi  ri.osis 

ohaiii^t'sof  specifically  tuberculous  nature,  we  may  suspect  a  stage 
ol  (juile  general,  not  specilic  phenomena,  which  lasts  a  consider- 
able time;  (3)  if  in  the  one  sort  of  infection,  in  ihis  case  {vom  the 
gastro-intestinal  canal,  a  dispersal  can  take  place  over  all  the 
groups  of  hnipli  glands  in  a  (omrete  case,  o\er  ilic  neck, 
bronchial,  and  mesenteric-  lymph  glands,  ilien  nianifesl  tuber- 
culosis must  not  always  be  confined  to  thai  region  or  group  ot 
hinphaiit-  glands  connected  with  the  poini  of  infcciion;  no  self- 
evident  i-onclusion  as  to  tlu-  point  of  entry  may  be  tlrawn  trom 
older  and  s|)eciall\-  pronouncetl  or  isolated  changes  of  specilically 
tuberculous  nature  \u  one  or  oilier  of  the  lymphatic  glands;  a  locus 
))n)i<)ris  rcsistcntiw,  a  tendency  of  \arious  groups  of  glaiuls  must 
be  supposed,  and  it  would  be  quite  wrong  in  every  res]-)eci  to  allow 
oneself  to  be  entirely  prejudiced  in  one's  opinion  of  the  pinni  of 
entr\-  bv  the  phenomena  of  evident  specilic  tuberculous  changes. 
In  other  words,  Bartel  denies  the  \-alidity  of  ihe  law  of  localization. 

Those  are  the  conclusions  logically  developed  from  Bartel's 
statements,  not  to  mention  the  hvpotheses  buili  upon  them  of 
latcncv,  of  destruction  of  the  bacilli  b}-  the  glandular  tissues,  t^c, 
to  wliit-h  we  shall  refer  in  another  ]:)lace.  The  results  obtained 
bv  Bartel  mav  be  thtis  explained.  The  animal  experiuKMTted  upon 
by  Bartel  with  its  latent  focus  of  a  Inmdred  and  four  days  was 
a  rabbit,  and  was  fed  with  lumian  bacilli.  Now,  rabbits  are  hardly 
susceptible  to  human  bacilli.  If  a  rabbit  be  inoculated  either  sub- 
cutaneously,  intestinal! \-,  or  by  anv  method,  with  human  bacilli, 
it  causes  no  appearance  of  irritation  in  the  glands,  being  inoffensive 
to  the  bodv  of  the  rabbit,  as  the  numerous  experiments  of  Weber, 
Oehlecker,  &c.,  have  pro\ed  ;  therefore  lliev  suffer  from  no  affec- 
tion of  the  glands  after  inoculation,  as  do  men  and  guinea-pigs; 
bui  the  bacilli  pass  through  the  glands  almost  like  granules  of 
Indian  ink,  without  exciting  the  glands  to  reaction,  and  so  arri\e 
in  the  blood  passages  and  then  in  the  lungs  and  other  organs.  Here 
they  may  exist  for  a  time  (as  in  Bartel's  case  for  one  hundred  and 
four  days)  without  producing  any  changes,  or  the\-  induce  slight 
but  not  specific  irritation  of  the  cells,  which  Bartel  designates  the 
lymphoid  stage  of  the  tubercle;  but  in  many  cases — with  a  stock 
that  is  specially  virulent,  or  in  the  special  susceptibility  of  the 
rabbit — they  form  real  tubercles  in  the  lungs  and  kidneys;  but 
these  are  mostly  of  transitory  character.  The  fact  that  thev  are  to 
be  found  more  in  the  glands  than  in  the  organs  is  explained  by  the 
fact  that  the  glands  are  reseryoirs  for  the  organs. 

The  whole  of  these  experiments  of  Bartel — which  induced 
Weichselbaum  to  make  a  stand  against  the  law  of  localization, 
and  which  induced  Salge  and  many  other  authors  to  fayour  the 


GKNKSIS    Ol'    S(  l<n|l'I/)SIS  99 

opinion  lli;ii  I  iihcK  iilosis  ol  ilic  <4lai)(ls  wiilioiil  pf,'r(:<;plibN; 
analomical  (  lian^cs  liad  Ixrn  (Icinonsl  lalcd,  a  \  ic\s  wliic.li  would 
inaui^uralc  vasl  (  liaiij^cs  in  ilic  opinions  ol  iIk-  |)oini  of  r-nlry 
(Cliiari)— lose  niiicli  ol  ilicir  \\ciL;lii  Ironi  llic  lari  dial  liarl«-i 
in(xailat('d  an  un.sinlal)lc  aniniai,  widi  nnsnilahic  I  uhi-rc  iiloii-, 
malcrial. 

Il  is  nol  a  (|iii'Slion  licrc  ol  inlands,  in  wliicli  n|)  lo  tli'il  linir- 
there  were  no  specilic  clian^cs,  dioni^li  diese  perlia|js  loiglil  lia\e 
arisen  later;  hut  il  is  a  (|iicsnon  ol  dw  presence  of  bacilli,  which, 
dioui^li  nc\cr  al  anv  hnic  rap,-il)lc  ol  producing  specific  changes 
in  llie  hodv,  would  have  died  oul  had  not  IJartel  saved  them  from 
exlinclion   by    inoculating   llicni   inio  another  susceptible  animal. 

Barlcl's  and  Weichselbaum's  protest  against  the  law  of 
localization  is,  therefore,  completely  unwarranted,  and  cannot 
be  maintained,  on  accoimt  of  the  misdirected  arrangements  of  his 
experiments. 

But  also  the  further  conclusion,  that  the  wh(jle  of  the  glandular 
system,  "  everv  group  of  glands,"  could  be  attacked  by  latent 
tuberculosis,  falls  to  the  ground  with  il,  not  to  mention  that  a  very 
natural  explanation  may  be  given  of  Jiartel's  concrete  case,  the 
simultaneous  pressure  of  bacilli,  active  of  themselves,  in  the  neck, 
mesenteric,  and  bronchial  glands  from  accidental  inspiration  of 
bacilli  at  the  time  of  feeding,  as  in  analogous  cases  of  Kovacs', 
without  assenting"  to  Bartel's  theory  of  "  dispersal  "  over  the 
whole  group  of  lymph  glands.  This  dispersal  over  the  whole 
group  of  lympii  glands  has  not  been  demonstrated  in  any  single 
case,  as  direct  spontaneous  infection  of  the  above  glands  is  not 
excluded. 

Further,  if  Bartel  has,  by  means  of  "artiticialh-  modified  " 
bacilli,  produced  in  animals  such  so-called  Ivmphoid  tubercles 
(swelling  of  the  follicles  and  endothelium  Ivmphoid  hvperplasia, 
which  are  the  low^est  degree  of  specific  change  of  tissue),  it  mav 
be  scientifically  very  interesting,  but  as  we  men  have  unhappilv 
to  reckon  with  infection  by  natural  bacilli  and  not  those  artificiallv 
modified  and  prepared  in  the  laboratorv,  these  laboratorv  experi- 
ments are  unimportant  for  human  pathologv  and  infection  as  it 
occurs  in  nature. 

But  how  long  will  it  be  before  references  to  these  achievements 
of  Bartel,  as  a  protest  against  the  law  of  localization,  disappear 
fn^m  our  literature  ? 

The  law  of  localization  agrees  completelv  with  our  experi- 
mental experience,  on  which  it  is  based;  till  now  no  proof  to  the 
contrarv  has  been  adduced  which  is  entirely  free  from  objection. 

Weleminsky  has  also  confirmed,   in  agreement  with  me,  bv 


lOO  SCROIULOSIS 

experiments  on  i,ooo  animals,  thai  when  infeclion  lakes  place  it 
is  alwavs  the  glands  of  that  part  which  are  first  infected;  Kossel, 
Weber,  and  Beitzke  have  also  arriveel  ai  like  results  after 
numerous  further  ex]5erinienls  on  animals. 

EXPERIMENTAL    ERRORS. 

Where  apparent  contradictions  occiu"  they  may,  as  a  rule, 
be  traced  to  the  faulty  arrangement  of  the  experiment  or  to 
mistakes  in  observation,  to  which  such  experiments  are  frequently 
exposed;  frequently  a  previous  spontaneous  infection  in  an  organ 
other  than  the  one  inoculated  may  give  rise  to  illusions,  or  the 
animals  are  allowed  to  live  too  long,  so  that  the  striking  differ- 
ences are  effaced;  ^•erv  frequenih-  a  too  large  (|uaniii\-  oi  material 
for  infection  is  emploved,  against  which  the  filtering  power  of  the 
glands  is  quite  impotent.  Thus  experiments  have  been  published 
which,  if  made  on  a  man  weighing  70  kg.,  would  represent  an 
intratracheal  injection  of  350  grammes,  an  o\erwhelming  dose  of 
tubercle  bacilli,  or  an  intraperitoneal  injection  of  i^-  litres  of 
infective  material.  Old  ctillures  of  unknown  \irulence,  doubtful 
vitalitv,  and  simplv  poisonous  acti\-ity,  or  an  unsuitable  type 
(human  type  on  rabbits)  will  derange  the  results;  thus,  in  Paris 
during  the  eighties,  for  a  long  time  "  Parisian  culture  "  of  the 
avian  type  was  unintentionalh-  employed,  and  Oehlecker  proved 
that  Weleminskv,  in  spile  of  his  assurances  to  ihe  contrary,  inocu- 
lated human  instead  of  ])ovine  bacilli,  without  being  aware  of  it. 
Often  the  material  for  inoctilation  in  a  different  series  of  experi- 
ments is  dissimilar.  In  subcutaneous  injections  small  vessels  are 
often  pierced,  and  unconsciously  direct  infection  of  the  blood  is 
produced,  frequently  unintentional  double  or  super  infection  is 
associated  in  the  cattle-shed  itself,  e.g.,  spontaneous  inhalation, 
or  intestinal  infection  by  means  of  tuberculous  material  from 
subcutaneous  foci  which  have  burst;  or  hv  incautious  handling 
of  the  material  for  inoculation  on  the  part  of  ser\-ants;  uninten- 
tional or  even  m^dicious  change  of  the  animals  bv  the  emplovees.^ 
In  most  cases,  too,  few  animals  are  used  for  the  experiments,  and 
so  accidental  divergencies  have  the  appearance  of  being  the  rule. 

All  these  vexatious  sources  of  error  take  place  oftener  than  one 
thinks,  and  may  exen  sometimes  happen  to  the  most  conscientious 
and  skilful  investigator.  ]\Tany  of  the  experiments  which  are  current 

1  The  influence  of  bicycle  riding  on  the  heart  was  being  tested  in  a 
clinic,  but  the  cyclists  preferred  to  go  to  the-  nearest  public-house  to  quench 
their  thirst  with  the  fee  thus  obtained,  and  afterward?  had  their  "  cyclist's 
heart "  examined. 


GENESIS    Ol    SCROl'LI.OSiS  lOI 

in  lilcr.-iliirc  and  .'icccplcd  as  /i  ic\ dai  inn,  and  f|iioicd  again  and 
again,  carry  willi  di('ni,  l<i|-  dio.sc  acciuaniicd  widi  di'-  niallcr,  tlKi 
stamp  of  their  defects  and  dicir  incredibility.  S'»  ninrli  die  more 
justilial)le,  then,  is  die  demand  Ihat  cxpciinifiiis  which  claim 
notice  should  not  be  made  on  twenty  or  ihiriy  animals,  but  on  a 
large  series,  that  they  should  be  tested  on  animals  krpt  to  control 
the  experiments  and  be  repeated  at  hasi  (.nee  more  under  different 
conditions  before  they  are  given  lo  die  literary  world,  and  that 
the  arrangement  of  the  experimeni  and  die  results  should  be  most 
exactly  communicated  even  lo  die  smallest  detail — a  strange 
demand,  perhaps,  in  the  present  day,  with  its  more  extensive  than 
intensive  work  and  haste  to  communicate  results  before  the  ink- 
is  dry  on  the  pa[)er. 

The  law  of  localization  agrees  entirely  with  the  experience  of 
morbid  anatomy  (Tendeloo,  Albrecht,  &c.),  which  teaches  that 
bacilli  may  migrate  through  skin  and  mucous  membrane,  but  are 
stopped  at  the  next  lymph  gland,  and  tuberculous  changes  are 
induced.  This  is  further  confirmed  by  anatomical  examinations 
of  the  lymph  system  by  Most,  Beitzke,  &c. 

We  are  therefore  certainly  justified  in  concluding  the  point 
of  entry  from  the  seat  of  a  primary  tuberculous  affection,  and  also 
justified  in  concluding  with  some  amount  of  certaini}-  its  relative 
age  from  the  intensity  of  the  focus. 

We  have  devoted  so  much  consideration  to  these  objections, 
because  the  la\v  of  localization  is  the  foundation  of  a  correct  concep- 
tion of  tuberculosis  and  scrofulosis  and  the  paths  they  follow.  That 
there  are  exceptions  to  the  rule  has  never  been  denied,  for  Nature 
knows  no  hard-and-fast  rule;  as  the  heart  sometimes  lies  on  the 
right  side,  and  a  man  is  born  with  six  fingers,  so  under  certain 
circumstances  may  the  bacteria  deviate  from  their  usual  paths, 
especially  at  their  first  entrance,  but  that  does  not  alter  the  rule 
any  more  than  the  cases  just  mentioned,  and  also  does  not  alter 
their  practical  importance. 

It  is  a  pity,  in  view  of  the  importance  of  the  law  of  localization, 
that  many  distinguished  investigators,  evidently  without  having 
given  any  very  deep  attention  to  the  question,  satisfv  themselves 
with  a  very  diplomatic  "  uon  liquet,"  and  so  indirectlv  abet  the 
most  daring  speculations. 

Many  hypotheses  have  arisen  and  again  disappeared ;  the 
theories  of  v.  Behring  would  have  been  avoided  from  the  verv 
first  bv  a  careful  consideration  of  experiments  on  animals  and 
their  consequences.  B.  Fischer  and  others  sav  :  "  Hamburger 
rightly  remarks  that  the  law  of  localization  is  an  ever-recurring 
fact,  and  is  observed  again  and  aeiain  bv  all  authors." 


I02  .sCROl-ri.OSIS 

A  turiher  question,  but  one  not  tlirci-ily  rdimctUxl  wiih  tlu^ 
law  of  localization  is,  what  is  the  t'urilicr  path  ot  llic  intfiiioii 
when  ii  Icaxcs  llu'  Kniphalic  inlands  sealetl  nrart-si  in  ihr  poini 
of  enir\  y      l-'or  furilicr  int'ormaiion,  sec  p.   ijj. 

Co'anlctl  tlu'  law  i^i  loralizal  i<  >ii.  llif  {iiu-siion  ot  the  most 
imporiani  souriH-  of  intVcrmn  in  man.  ilial  ot  inhalaiion  hy  ilic 
lun^s.  is  sflllt'il.  Tendeloi),  luiycn  Alhrcclit,  Cloklschniitl,  \-.. 
Kaufinann.  .Most,  Spronck,  Ribberl.  i.uharscli  recently  dcclarccl 
themselves  for  ii  on  ihe  i^round  of  liicir  anatomical  cxpcri- 
ences ;  ^•.  Schr(")itcr,  Alonigom(M'\ ,  A.  l''r;inkcl  on  the  ^roinid  ot 
clinical  fads  (at  least  for  adults') ;  and  Gei|X'l,  Beitzke,  Winkler, 
McLJin,   Mallinkrodt,  &c.,  for  children. 

The  preponderance  of  tuber^-idosis  of  the  lun^s  o\-er  intes- 
tinal infection,  v\vn  if  we  concede  numerically  ec|ual  opportunities 
of  infection,  is  to  be  explained  by  the  fact  that,  among-  all  classes 
of  animals  which  haxe  up  till  now  been  experimented  upon,  con- 
siderably fewer  germs  of  infection  are  necessary  for  infection  of 
the  lungs  than  the  intestines. 

Thus  in  parallel  experiments  by  Kuss  and  Lobstein  extensive 
tuberculosis  of  the  lungs  appeared  after  inhalation,  whereas 
animals  fed  with  the  germs  remained  healthy.  Pfeiffer  and 
Friedberger  caused  animals  to  inhale  ,^,000  tubercle  bacilli  ; 
amongst  twentv-nine  animals,  twentN-two  had  tuberculosis  of  the 
lungs,  whilst  among  twenty-eight  animals  fed  by  means  of  the 
cesophageal  tube  with  3,000,000  tubercle  bacilli  three  had  slight 
tuberculosis  of  the  mesenteric  glands,  four  had  isolated  foci  in  the 
lungs  from  aspiration,  and  twenty-one  showed  no  changes. 

According  to  Bongert,  rats,  which  are  hardly  susceptible  to 
tuberculosis,  can  with  difficultv  be  infected  subcutaneoush'  or 
per  OS,  but  with  inhalation  the}'  were  infected  without  exception. 
Reference  must  be  made  to  the  small  quantity  of  tubercle  bacilli 
required  by  Findel,  Lafifert,  Reichenbach,  Alexander,  \\>l)er,  to 
induce  infection  by  inhalation,  against  the  enormous  quantities 
which  were,  as  a  rule,  required  to  produce  intestinal  infection. 
(For  details  and  reasons,  see  p.   114.) 

li  is  an  important  question,  especially  with  reference  to  the 
later  fate  of  those  suspected  to  be  suffering  from  scrofulosis,  who 
have  tuberculosis  of  the  tonsillar  or  neck  glands,  whether  the 
tubercle  bacilli  can  arrive  by  a  more  direct  Kmphatic  passage  from 
the  organs  of  the  neck  (besides  their  dispersal  bv  the  blood 
passages  through  the  usual  anatomical  channels,  through  the 
thoracic  duct,  and  superior  \-ena  cava  on  the  right  side  of  the 
heart),  either  through  the  supraclavicular  glands  to  the  summit 
of  the  pleura  and  the  apices  of  the  lungs,  or  in  a  continued  chain 
to  the  bronchial  glands,  and  so  produce  lubennilosis  of  the  lungs. 


GICNICSIS    Ol'    SCKOI-CLOSIS  lOJ 

Aiifrcclil,  (irolxT,  kiiinpli,  IW-ckrnann,  M.  VVasscrmann  con- 
sider llic  loiisils  Id  !)'•  one  ol  ilic  mosi  frf-(|iicnl  points  oi  enlry  of 
tuberculosis,  .-ind  ili;ii  i  iilxTculosis  ol  iIk-  1iiii.l(s  arises  from  iliem. 
(See  also  v.  licliriui;,  (iochcdini  .-ind  Koux,  Josscr/ind, 
Freudcndiai.) 

Now  die  tonsils  arc  nol  so  irc(|ucnd\-  t  iihciv  iiloiis  dial  tliey 
can  be  considered  as  a  decisive  [)oinl  of  cniry.  VVex  found  in 
2i()  cases  of  pliarynj^'-eal  tonsil  X?>  P"^"''  ''•ni.;  Lubarsch  in  I'f)sen 
1 '5  pel-  ccnl.  anions^'  sixlv  tonsils  in  (liildicn;  |'"ri«-din,-inn  only 
once  found  primary  tuberculosis;  Calm  lomid  prini.-iry  tubercu- 
losis of  the  pharvnn-cal  tonsils  in  about  4  p'-i-  (cni.  ot  the  cases 
of  adenoids.  ()nl\-  (IcM-dclcr  yi\cs  hi<4li('r  li^-urcs  in  pharyngeal 
and  palatine  tonsils  1275,  but  his  cases  are  to(j  few — f(jrty-seven 
in  all — and  therefore  more  subject  to  chances  (see  pp.  140,  ike). 
G(")rdeler's  discoveries  (upon  which  Aufrccht  takes  his  stand) 
of  tuberculosis  of  the  tonsils,  neck,  and  bnjnchial  glands,  with 
and  without  tuberculosis  of  the  lungs,  are  just  as  little  con- 
firmatorv,  as  the  tuberculosis  of  the  lungs  and  bronchial  glands 
mav  just  as  well  have  arisen  by  inhalation,  from  the  same  source 
of  infection,  independently  of  the  tonsils. 

Aufrecht,  denying  tuberculosis  by  inhalation,  considers  the 
path  from  the  organs  of  the  neck  to  the  bronchial  glands  as  "  the 
onlv  one  that  has  been  proved,"  and  attempted  to  confirm  this 
opinion  bv  se\'en  experiments  on  rabbits,  whose  pharyngeal 
organs  were  "  painted  "  with  a  swab  of  wadding  dipped  in  the 
lung  of  a  phthisical  tul3erculous  person.  No  theory  can  be  con- 
firmed by  seven  experiments  on  animals.  Besides  which,  two  of 
these  animals  were  healthv  after  a  period  of  two  years;  one  died' 
prematurely,  so  only  four  remain,  of  which  two  at  most,  by  the 
most  charitable  interpretation,  can  be  said  to  confirm  the  possi- 
bility of  Aufrecht's  path  of  infection,  inasmuch  as  the  neck  glands 
and  lungs  exhibited  isolated  foci.  But  there  can  be  no  question 
of  proof,  for  it  is  infinitely  more  probable  in  this  case  that  these 
foci  in  the  lungs  were  due  to  inhalation  of  the  infective  material, 
in  consequence  of  the  choking  movements  caused  by  painting  the 
walls  of  the  pharynx.  It  may  be  noted  incidentally  that  the  con- 
dition of  the  glands  remarked  by  Aufrecht  is  contrary  to  our 
experience  (Weber,  Oehlecker),  according  to  which  rabbits,  after 
infection  bv  the  hiunan  type  of  bacillus,  exhibit  no  affection  of 
the  glands. 

Finally,  anatomical  reasons  can  be  adduced  against  Aufrecht's 
path  of  infection,  for  both  Beitzke  and  Most  found  in  their  examina- 
tion of  the  path  of  the  lymph  channels  that  no  lymph  vessel  could 
be  discovered  leading  from  the  neck  to  the  bronchial  glands  (see 
p.    122).     But  supposing  that   now  and  again  bacilli  could  reach 


104  SCROl  TLOSIS 

the  bronchial  glands  by  collateral  paths,  wc  nuisi  not  think  that. 
on  the  ground  of  this  anatomical  possibility,  the  ciiiiiiions  rouit- 
is  the  rule. 

Grober  supposes  that  llu-  bacilli  reach  the  sujiraclaxiciilar 
glands  from  the  neck  glands,  and  so  arri\e  direct  to  the  siunniii 
of  the  pleura  and  the  apices  of  the  lungs.  He  refers  to  his  experi- 
ments in  which,  after  injecting  Indian  ink  into  the  tonsils,  he 
traced  the  granules  to  the  pleura  and  apices  ot  the  lungs. 

Beilzke's  after-test,  ho\ve\er,  makes  it  probable  that  the  result 
obtained  bv  Grober  rests  on  an  error  in  the  experiment;  anil 
this  result  mav  be  explained  by  the  pt)ssibility  of  aspiration  into 
the  trachea  of  some  of  the  fluid  used  or  of  some  of  the  injection 
which  had  been  again  pressed  out  of  the  tonsil.  Neither  he,  nor 
Hart,  nor  Most  succeeded  in  infecting  the  lym]-)!!  \(\ssels  leading 
from  the  lower  cervical  glands  in  the  pleura  (see  p.  124). 

\\'ood  considers  the  advance  of  a  tuberculous  peri-adeniiis 
from  the  lowest  cervical  gland  as  possible,  but  rare,  whilst 
Aufrecht,  in  opposition  to  Grober's  experiments,  emphasizes  the 
differences  between  the  unnatural,  enormous  inundation  of  the 
finest  non-irritant  granules,  caused  by  the  pressure  of  the  injection, 
and  infection  l)y  bacilli  which  irritates  the  tissues.  So  infection 
of  the  bronchial  glands  and  lungs  through  the  organs  of  the  neck 
is,  up  to  date,  not  proved  with  certaintv,  and  although  from  the 
results  of  experiments  it  is  not  to  be  entireh'  denied  (see  p.  126),  it 
cannot  be  taken  as  of  frequent  occurrence;  for  the  simple  fact  that 
in  tuberculosis  of  the  lungs  frequently,  and  with  adults  as  a  rule, 
tuberculosis  of  the  neck  glands  is  not  present,  refutes  this  idea. 
But  if  bacilli  could  reach  the  bronchial  glands  from  the  neck 
glands  they  would  form  a  necessary  connecting  link. 

If  children  with  scrofulous  neck  glands  develop  tuberculosis 
of  the  lungs  later,  we  may  consider,  as  a  rule,  that  indejiendent 
further  infection  of  the  lungs  has  taken  place  by  inhalation,  unless 
we  have  to  do  with  infection  of  the  blood,  an  invasion  of  the 
bacilli  into  the  blood  channels,  an  admission  which  imposes 
increased  caution,  especially  in  its  prophvlactic  bearing.  (It  's 
not  the  place  here  to  enter  into  Aufrecht 's  further  hvpotheses  on 
the  h^emalogenous  genesis  of  tuberculosis  of  the  lungs.) 

B.— BOVINE  TYPE. 

As  we  have  seen  in  the  spreaB  of  tuberculosis,  the  repre- 
sentative of  which  (consumption  of  the  lungs)  causes  eleven- 
twelfths  of  all  fatal  cases,  tuberculosis  amongst  cattle  comes,  in 
general,  little  into  consideration.  But  it  forms  a  very  considerable 
source  of   scrofulous  tuberculosis,    especially   tuberculosis  of   the 


GENESIS    <)l'     SCKOi'LLOSiS  IO5 

neck  and  mescnicric  l^I.'ukIs.  lim  w-  <  ,-inn<ii  siiflicif-nlly  sludy  its 
full  iini5ortance  on  accoiini  ot  ilic  (IiIVk  iili  m's  of  conlirmalion. 

Before  we  pass  on  lo  pari  irulars  ii  would  Ix-  well  lo  casta 
glance  at  the  epidemiological  and  slaiisiical  researches  as  lo  the 
connection  between  bovine  and  human  tuberculosis,  whicli  will 
open  up  important  points  of  view  for  scrofidosis. 

r)iderl,  with  his  brother,  coidinncd  in  .\llg;iu  thai,  in  .s|)ile 
of  the  great  consum|)lion  of  raw  mill<,  human  tuberculosis 
amongst  the  entire  p()|)ulalion  is  not  dcpciKlciii  on  ilif  frc(|ucncy 
of  bovine  tuberculosis.  Acccjrding  to  Meyer,  in  J'^ngland  and 
other  linglish-speaking  countries,  in  spite  of  the  customary 
drinking  of  raw  milk  and  a  large  percentage  of  tu1)ercle  bacilli 
in  the  milk,  the  l(^lal  number  of  persons  suffering  from  tubercu- 
losis is  much  lower  than  on  the  fuiropean  continent,  where, 
as  a  rule,  milk  is  boiled  before  being  used.  Inversely,  tubercu- 
losis causes  a  higher  rate  of  mortality  in  Sicily  and  Sardinia, 
although,  according  to  \"estea,  bovine  tuberculosis  is  almost 
unknown  in  those  islands.  In  Minister  and  Osnabriick,  in  spite 
of  frequent  human  tuberculosis,  bovine  tuberculosis  is  very  rare. 
Amongst  6,500  oxen  which  were  slaughtered  not  a  single  one 
was  tuberculous  (Kasselmann).  In  nine  poor  villages  in  the 
•district  of  Oderbruch,  with  1,637  head  of  cattle,  during  six  years 
there  was  no  death  from  bovine  tuberculosis,  whilst  human  tuber- 
culosis is  of  frequent  occurrence  in  this  district  (Zippelius). 

In  the  provinces  of  Denmark  the  spread  of  human  tubercu- 
losis does  not  run  parallel  with  that  of  bovine  (Rordam). 

In  Japan  there  is  high  mortality  from  tuberculosis  among 
children,  although  till  a  few  vears  back  the  consumption  of  beef, 
and  more  especiallv  the  drinking  of  cow's  milk,  was  almost  un- 
known. The  same  is  reported  of  China,  the  Philippines,  and  the 
Gold  Coast,  of  Turkev,  and  Greenland  (Shiga,  Kitasato,  Cobb, 
R.  Fisch,  Rordam,  Heymann).  In  certain  parts  of  Roumania 
tuberculosis  is  verv  widespread  in  districts  where  cow's  milk  is 
never  given  to  children.  Similar  observations  have  been  made 
by  V.  Stark  in  Prussia,  Ganghofner  in  Bohemia,  v.  \^ogel  in 
Bavaria. 

Exceptions  to  this  rule,  w^iich  have  been  communicated  from 
observations  made  in  small  districts,  such  as  from  Sabotta,  are 
subject  to  chance,  and  therefore  cannot  be  taken  into  consideration. 

The  preceding  statements  compare  bovine  tuberculosis  with 
human  tuberculosis  in  general,  that  is.  with  phthisis  of  the 
lungs,  and  are  therefore  at  the  same  time  valuable  documents 
against  the  opinions  formerly  held  bv  v.  Behring,  that  infection 
by  tuberculous  milk  was  the  cause  of  phthisis  in  later  life  (it  is 


I06  SCIUM-LLOSIS 

known  ilial  later  \'.  liehring  ga\e  a  dilTereni  inicrprciaiion  to  his 
thesis).  These  results  prove  tliat  there  is  no  statistical  connection 
between  bovine  tuberctilosis  and  the  drinking  of  milk,  and  they 
contradict  in  a  tlecided  manner  the  idea  of  a  change  b\-  culture  of 
box  ine  into  human  bacilli,  also  ilu*  iransiiion  of  scrofulosis  t)f  the 
neck  or  mesenteric  glands  io  phthisis. 

We  get  (|uite  a  different  picture  when  we  comjDare  boxine 
tubcM-culosis  statistically  with  abdominal  tuberculosis,  which  is 
partl\-  dependent  on  it.  Thus  in  h'ngland,  where  more  unboiled 
milk  is  drunk  than  in  (u-rmanv,  tuberctilosis  of  the  intestines  and 
mesenterv  is  apparenih-  more  frecjtient  (Cattle).  According  to 
Raw,  human  tubercuK)sis  is  on  the  decline  in  England,  whilst 
abdominal  and  b()\ine  tuberculosis  is  on  the  increase.  In 
countries  where  little  milk  is  used,  as  in  India  and  I'lgvpt 
(Ilevman),  bo\-ine  tuberculosis  is  rare  (Raw),  in  spite  of  more 
fre(|uent  phthisis  amongst  adults.  In  India  the  natives  and 
children  are  almost  free  from  tuberculosis,  whilst  Europeans 
freciuentlv  suffer  from  it ;  the  former  take  neither  beef  nor  cow's 
milk,  only  goat's  milk.  (Reid,  quoted  from  Raw.)  On  ninety- 
seven  Norwegian  farms  0\-erland  found  a  greater  or  lesser 
frequency  of  human  and  bovine  tuberculosis.  On  forty-three 
farms  where  there  were  tuberculous  persons,  522  animals  (6"7  per 
cent.)  reacted  positively. 

On  lifty-four  farms  without  tuberculous  persons,  635  animals 
(i'^  per  cent.)  reacted  positivelv;  on  the  other  hand,  on  thirlv- 
four  farms  where  there  were  tuberculous  cattle,  tuberculous 
persons  were  found  twent}-one  times  (61 '7  per  cent.). 

On  sixty-three  farms  without  tuberculous  cattle,  tuberculous 
persons  were  found  twenty-two  times  (34"9  per  cent.). 

The  positive  reaction  may  as  well  have  been  caused  by  the 
bovine  as  by  the  human  type,  and  be  due  entirely  to  tuberculosis 
of  the  neck  and  mesenteric  glands. 

According  to  Tedeschi  and  Lorenzo,  phthisis  is  very  rare  in 
a  population  which  was  solely  of  pastoral  habits,  living  always 
in  the  fresh  air;  but  tuberculosis  of  the  glands  and  bones  and 
scrofulosis  were  very  general. 

Davies  found  in  London  from  1892  to  1902  a  decrease  of  almost 
one  half  in  ihc  morialiix'  from  tuberculosis,  tabes  mesenterica,  and 
tuberculous  peritonitis,  and  ascribes  it  to  better  weeding  out  of 
tuberculous  cows  and  a  more  careful  sterilization  of  the  milk. 
Raw  made  the  same  obser\'ati(^n  as  to  Lixerpool. 

On  the  contrar\',  according  to  Tonzig,  tabes  mesenterica  is 
more  prevalent  in  Italv,  in  Bari,  Avellino,  where  verv  little  cow's 
milk-  is  consumed  and  where  goat's  milk  is  drunk',   than  in  other 


c;iiNi::.si.s   oi'    s( Koii  i.osis  107 

towns,  ('■ii'.,   I'.'iA'i.'i,   I'i.'iccn/.'i,  (Omo,    licr^amo,   wlu-rc  cow's  milk 
is  more;  especially  (Inink. 

Anyway,  llie  spread  nt  Ixiviiie  I  iil)ei(  iil<  isis  ap|)cars  lo  exert 
an  inlliience,  slal  islical  1  \-  pioxed,  on  I  lie  tre(|tiency  of  1  iiberculosis 
of  the  oi'sjans  of  dis'cslion,  \\lii(  li  also  iiK  hides  a  ijarl  of  scrofu- 
losis,  but  wliicli  is  suhjecl  lo  •j;rc:\\  \aiiaiioiis  Irom  \\\<-  different 
local  manners  and  cnslonis  of  llie  popul'ition  ((onsinnpl  ion  of  raw 
or  boiled  milk,  Sic). 

Extent,  Degree,  and  Danger  of  Bovine  Infection. 

llie  genesis  of  scrofulous  luberculosis  was  in  pari  onl)'  intel- 
ligible to  us  through  a  more  exact  knowledge  (jf  ben  ine  infection 
in  man. 

Opporlimiiies  of  infeclion  through  tuberculous  cattle  differ 
widely  from  those  llirough  tuberculous  pers(jns.  in  the  latter 
the  secretions,  especially  the  dried  expectoration  of  those  with 
an  affection  of  lh(>  lungs,  pla\'  the  principal  |)ari  in  infe(tif)n. 
With  tuberculous  cattle  this  danger  falls  into  the  background, 
for,  as  a  rule,  we  have  here  to  do  with  foci,  and  where  open  foci 
appear,  the  expectoration  is  swallowed,  and  onl\-  appear  again  in 
the  excreta;  the  air  of  the  sheds,  which  is  usually  moist,  prevents 
pulverization  of  the  hygroscopic,  sticky  conglomeration  of  bacilli ; 
in  the  open  air  the  dispersal  of  the  bacilli,  in  the  enormous 
ocean  of  the  air,  hardly  offers  a  real  danger  in  the  vicinity  (Cornet, 
"Die  Tuberculose,"  second  edition,  p.  105). 

Now  and  again  by  the  coughing  of  the  cattle,  or  b\-  nasal 
secretions  containing  bacilli,  the  germs  may  be  dispersed,  and,  in 
the  case  of  close  contact,  may  endanger  the  human  respiratorx' 
passages. 

Adults  are,  however,  protected  from  actual  disease  bv  their 
high  power  of  resistance  to  bovine  bacilli ;  but  if  children  are 
much  in  the  cowsheds  or  live  with  the  animals,  infection  of  the 
respiratory  organs,  especially  of  the  bronchial  glands,  which  runs 
a  favourable  course,  mav  take  place. 

Doubtless  meal,  milk,  and  milk  products  are  a  far  more 
important  source  of  infection. 

Opportunities  of  Infection  by  Tuberculous  Meat. — The  least 
dangerous  of  these  sources  is  the  flesh  of  tuberculous  animals, 
especially  in  its  natural  form,  because  as  a  rule  the  diseased  parts 
lie  at  a  distance;  it  is  much  more  dangerous  when  chopped  up, 
and  especially  in  the  preparation  of  sausages,  in  which  unscrupu- 
lous manufacturers  oft'er,  with  tempting  appearance,  to  the  con- 
fiding public,   big  and  little,    high  and   low,    those  parts  of  the 


io8  scRoruLOSis 

beasi  which  iire  tuberculous,  diseased,  and  loallisome.  The 
secrets  of  the  sausage  machine,  the  extensive  commerce  in  sausage 
meat,  and  the  barrel  upon  barrel  of  uihcrculous  lungs,  liver,  and 
scraps  form  a  constant  subject  tor  our  law  courts,  and  give  us  an 
idea  of  the  quantities  of  meat  in  the  market  containing  tubercle 
bacilli. 

Also  the  meat  and  refuse  of  tuberculous  pigs,  especially  in 
sausages,  must  be  included  in  the  opportunities  for  infection,  more 
especiallv  as  the  pig  is  very  susceptible  to  both  types  of  tubercle 
(Kossel  and  Weber).  The  bovine  infection  is  mostly  found  in 
consequence  of  the  frequent  feeding  with  tuberculous  skimmed 
milk  from  dairies. 

According  to  the  experiments  of  Tonzig,  the  tubercle  bacilli 
retain  their  vitality  a  long  time  in  sausages  and  smoked  provisions. 

The  danger  of  tuberculous  infection  by  means  of  meat  sup- 
plies is  in  general  little  considered,  perhaps  too  little,  for  it  seems 
just  the  slow  mastication  and  swallowing  of  solid  material,  as 
sausages,  although  it  may  not  contain  so  many  bacilli  as  tuber- 
culous milk,  must  endanger  the  tonsils  and  neck  glands  to  a 
greater  degree  than  the  transient  passage  of  milk,  and  lead  to  the 
adhesion  of  small  infectious  particles  in  the  recesses  of  the  tonsils, 
especiallv  when  they  are  in  a  hyperplastic  condition  through  a 
state  of  pyogenous  irritation. 

Opportunities  of  Infection  by  Milk. — The  greatest  danger  of 
bo\"ine  tuberculosis  occurs  in  man,  especially  in  children,  by 
means  of  milk  and  its  products,  butter,  cheese,  and  curds  and 
whev,  in  which  the  tubercle  bacilli  which  were  present  in  the  milk 
retain  their  vitality. 

The  following  figures  show  the  abundance  of  these  sources 
of  infection.  According  to  Glage,  there  were  in  the  German 
Empire  in  1905,  amongst  the  animals  slaughtered,  I7'39  per  1,000 
cattle,  o"9i  per  1,000  calves,  4*26  per  1,000  pigs,  which  were 
affected  with  important  forms  of  tuberctilosis,  according  to  the 
veterinary  inspectors;  among  the  cattle  the  principal  contingent 
was  cows. 

Tubercle  Bacilli  contained  in  Milk. 

P'xamination  of  the  milk  itself  gives  us  the  best  information; 
54  per  cent,  tubercle  bacilli  were  demonstrated  in  milk  samples, 
and  47  per  cent,  in  samples  of  butter  (Noncwitsh,  in  Wilna). 

In  210  milk  samples  put  on  the  market  in  Leipzig,  Eber 
found  tubercle  bacilli  in  22  (io"5  per  cent.) ;  in  150  butter  samples, 
18  (12  per  cent.);  in  50  cream  and  curds  and  whev  samples  4  per 
cent. ;  150  margarine  samples  contained  no  tubercle  bacilli. 

In  the  milk  of  New  York,  A.  Hess,   in   107  samples,  could 


GliNIiSIS     or    SCKOMJLOSIS  IO9 

|)r()V('  virulcnl  liilxTcii'  h.-uilli  in  i'^)  p'l'  rcnl.;  (iorion  in  10  p(;r 
ccni.  Ani()n<4Sl  \ni)  srniiplcs  ol  null;  inv  sale  in  London,  KU-in 
foimd  hibcrcU^  bacilli  sc\cn  limes,  Kolx-rlson  nixl  Maholni  in 
Birmingham  (America)  in  mcjre  llian  lo  per  cent.,  and  milk 
from  railway  stations  in  14  per  ca-iM.  (See  also  IJndenslein's 
statistics.) 

We  must  realize  in  this  connection  that,  according  to  Oster- 
mann,  in  3  c.cm.  of  milk  from  a  cow  w^ilh  a  lubcrciilous  udder, 
50,000  to  100,000  tubercle  bacilli  are  n<ii  nn((.ninion;  there  may 
be  even  1,000,000.  Bang  found  in  one  singh;  Held  of  vision 
200  bacilli,  a  quantity  which  in  the  ordinary  mixed  milk  which 
comes  into  the  market  sinks  to  about  1,000  bacilli  in  i  c.c:m.  of 
milk,  100  bacilli  in  butter  (v.  Bongert,  Kuhn,  Ostertag). 

According  to  the  inquiry  of  the  Agricultural  Society,  Kiihnau 
reckons  the  numl^er  of  animals  in  Germany  suffering  from  tuber- 
culous udders  as  50,000  to  100,000  among  a  total  of  10,000,000 
milch  cows.  These  cows  with  tuberculous  udders  give,  according 
to  Kiihnau,  50,000,000  to  100,000,000  litres  of  milk  containing 
tulx-rcle  bacilli,  which  exposes  about  700,000  persons  to  the  danger 
of  taking  tuberculous  milk. 

Primary  Tuberculosis  of  the  Intestinal  Canal. 

Infants  are  most  exposed  to  danger,  both  by  their  great 
susceptibility  for  the  bovine  bacilli  and  also  by  their  being  often 
fed  entirely  on  milk;  but  in  highly  civilized  countries  they 
generally  have  boiled  milk,  and  although  the  degree  of  heat  is 
often  insufficient,  and  the  one  short  boiling  is  not  sufficient  to 
destroy  all  bacilli  contained  in  the  milk,  the  danger  is  lessened, 
though  not  entirely  avoided.  In  the  following  years  of  childhood, 
when  milk  and  butter  are  freely  consumed,  the  number  of  oppor- 
tunities for  infection  are  much  greater,  in  fact,  enormously  great ; 
but  apparently  the  number  of  real,  infections  which  exhibit  them- 
selves mostly  in  the  intestinal,  mesenteric,  and  neck  glands  does 
not  agree  in  the  slightest  with  the  magnitude  of  opportunities  for 
infection,  for  primary  tuberculosis  of  the  intestinal  and  mesenteric 
glands  is,  according  to  repeated  experience,  relatively  rare. 

Morbid  Anatomy  Experience.— ^According  to  Baginsky,  intes- 
tinal tuberculosis  is  almost  unknown  amongst  infants;  in  933 
cases  of  tuberculosis  in  children,  he  never  found  isolated  intestinal 
tuberculosis  without  disease  of  the  lungs  and  bronchial  glands ; 
and  amongst  a  further  806  post-mortem  cases  most  carefully 
examined,  in  which  144  persons  were  tuberculous,  six  had 
caseous  tuberculosis  of  the  viscera,  and  most  of  them  between 
the  ages  of  5  to  10  years.  Mendelsohn  found,  amongst  278 
autopsies  on  infants  (fifty-seven  of  whom  were  tuberculous),   no 


no  SCROFLLOSIS 

single  cast'  of  primar\-  lulH'rfuldsi.s.  Also,  aiHoicliiii;"  lo 
Heuhiifi",  pi"iniai"\  inirsiinal  luhniulosis  is  wvv  rare;  in  troin 
8,000  10  10,000  autopsies,  \.  Uanseiiiann  only  eonliinieel  iweniy- 
five  cases  of  jirinKir\'  intestinal  tuberculosis;  llunter,  amongsi 
5,142,  thirteen  cases  (o'25  per  cent.);  Bietleri,  aiuoni^si  .;,io4 
tul)!M\Hilous  iliiklren,  .onlv  sixteen  cases. 

In  ilif  C'liariic  Hospital,  during  t"i\e  \ear.s,  iinl\  ten  cases 
c)f  priniar\'  intestinal  iul)erculosis  occurred  (X'ircliow )  ;  aniongst 
131  children  Onli  found  intestinal  tuberculosis  in  i'3  per  cent. 
(Koch).  Benda,  wiili  his  \cr\  large  number  of  patients,  onl\- 
nieniii)ns  two  lo  three  cases  of  really  priinar\  intestinal  tuber- 
culosis in  one  and  a  half  years. 

Tendeloo  also  enij')hasizes  its  extrenu-  rareness,  and  Ribbert 
and  Aibrec-lii  express  similar  opinions. 

Further,  /aim  found  in  0,320  autopsies  (including  a  few 
children),  amongst  which  2,058  \vere  on  tuberculous  persons, 
fort\-three  cases  of  primary  intestinal  tuberculosis,  and  according 
to  Jj'ifHer,  Grawitz  in  Greifswalde,  in  1,934  autopsies,  amongst 
which  320  were  on  tuberculous  persons,  only  four  cases  of 
intestinal  tuberculosis,  and  even  these  could  not  be  stated  with 
certainty  to  be  primary.  Also,  according  to  Krabler,  primary 
intestinal  tuberculosis  is  almost  unknown  in  Greifswalde,  although 
Loflfler  fountl  in  mixed  butter  88  per  cent,  of  tubercle  bacilli.  In 
Tiibingen,  amongst  1,407  autopsies  on  tuberculous  persons, 
Grosser  only  found  one  case  (Koch,  see  also  Lomini,  Rowland 
Godfrey,  and  Freeman).  Heller  and  Wagener  give  higher 
figures.  Heller,  who  at  the  same  lime  emphasizes  the  fact  that 
much  unboiled  milk  is  consumed  in  Holstein,  .found  in  I'viel 
amongst  714  children  who  died  of  diphtheria,  140  with  tuberculosis 
of  the  lungs,  53  with  primary  tuberculosis  of  the  digestive  organs 
— 74  per  cent,  of  the  diphtheritic  cases,  37*8  per  cent,  of  the 
tub(  rculous  cases.  In  seventy-six  autopsies  of  children  from  i  to 
15  years  of  age,  Wagener  found  thirteen  (171  per  cent.)  with 
primary  tuberculosis  of  the  intestines  and  mesenteric  glands  with 
evidence  of  bacilli,  and  three  without  bacilli,  and  se\-entecn 
(22*4  per  cent.)  with  tuberculosis  of  other  organs. 

Heller  and  Wagener  seem  to  have  reckoned  amongst  their 
ca.ses  thf)se  in  which  a  simultaneous  lubercuknis  bronchial  gland 
and  a  healed  tuberculous  focus  in  the  lungs  made  the  primar\ 
affection  doubt  fid. 

In  220  cases  of  diphtheria,  Councilmann,  .Mallorv,  and 
Pearce  in  Boston  found  thirt\--ri\e  with  luberctdous  foci,  thirteen 
with  primary  intestinal  tuberculosis,  making  5*9  per  cent,  of 
diphtheria,  and  37*1    per  cent,  of  tubertailosis. 


GENESIS    <jF    SCKOl'CI.OSIS  I  1  I 

In  conlrndiclioii  in  llillci-,  who  ;ili  rihiiifd  iIm  low  rij^iircs  of 
other  authors  lo  laiilU  !<■(  Iiiiii|ii<'  in  (h:-,:.<'<  i  ion,  ( ,;iiij4hofncr  found 
in  (he  I 'al  liolo^i<;i  I  Insliliilc  in  I'r.'ijMir  <)-j^  [MM'sons  wlio  <h'-(l  of 
acute  inlcclious  (hsc'iscs,  ol  whom  2-^j.  w<-r<'  i  iiherculous  palienis; 
lonlv  li\<'  c'lscs  ol  |)iim;ir\  inicsi  in;i  1  iiil  mt(  iilosis  were  found, 
niakino-  2  |)er  ccnl.  ot  ilic  I  iil)»'i(  iilous  p.-ii  icnis.  I><-it/k'e  reckons 
amon^sl  luhcrculous  (liihhvn  if)  lo  20  per  (cnl.;  I'rice-Jones 
(I'ln^land)  ahoul  25  per  ccnl.  who  .suHri-  Ironi  primary  inlcslinal 
tuberculosis  ((|Uolc(l  Ironi  licilzk-e);  I'-ibigcr  and  Jensen  reckon  dial 
priniarv  inlestinnl  Inhcrculosis  is  lo  he  found  auiongsl  (>  jjer  cent, 
of  all  patients,  and  1  1  per  ccnl.  of  <dl  siilTerin^^  from  tuberculosis, 
and  amonmsl  children  even  it)  per  cenl.,  a  rein,'irk;il)ly  hi^di  fi^^ure 
(see  also  Ipsen),  for  which  al  preseni  no  explnnaiion  cun  \)<-  found. 
The  vast  differences  may  be  caused,  ])arlly  l)\  iln  dilleicnce  of 
material,  bv  the  at;e,  l)\'  the  different  conception  of  ilie  chan^^es 
due  to  the  disease  (chalky  foci,  (^c),  and  also  parily  by  not  taking 
the  smallest  foci  into  account.  This  much  is  clear  from  all  these 
details,  that  even  if  we  accept  the  highest  figures,  primary  intes- 
tinal and  mesenteric  tuberculosis  is  not  nearly  so  widespread  as 
Ave  are  led  to  expect  from  the  excessively  fre(|ueni  oppcjrtunities 
of  inundation  with  l)acilli  to  which  the  human  chgestive  canal, 
especiallv  in  children,  is  exposed. 

The  disproportion  between  opportunity  and  infeciion  is  so 
much  the  more  accentuated  because,  amongst  the  cases  of  primary 
intestinal  tuberculosis  only  part  are  caused  by  bovine  bacilli  and 
others  by  the  human  type. 

Milk  containing  tubercle  bacilli,  which  in  calves,  pigs,  and 
sheep  so  easilv  causes  tuberculosis  (whilst  these  animals  when  fed 
with  tuberculous  sputum  are  seldom  or  never  infected),  is 
evidentlv  not  to  anv  great  extent  dangerous  for  mankind. 

Clinical  Experience. — Clinical  experience  has  but  in  few  cases 
shown  in  a  manner  free  from  all  objections,  i.e.,  by  absolute  proof, 
that  the  intestinal  malad}-  is  of  bovine  nature,  b\-  demonstrating 
that  the  food  was  infectious,  and  that  there  was  no  possibility  of 
anv  other  mode  of  infection — that  a  tuberculous  disease  was  the 
immediate  consequence  of  the  C(Misumption  of  food  containing 
bovine  bacilli. 

The  older  observati(ins  of  the  same  sort  recorded  by  Ollixier. 
Grosse,  Stange,  Johne,  Uffelmann,  Goring,  Schongen  (Koch  has 
collected  twenty-eight  such  cases  from  literature  on  the  subject 
and  closely  criticized  them),  and  the  cases  of  v.  Hansemann, 
Cowie,  Hiils,  cannot  be  accepted  as  conclusive  evidence  in  all 
respects. 

Recentlv  a  series  of  cases  has  been  commimicated,  accordino; 


112  SCROITLOSIS 

to  which,  even  after  KmL;-  cdiiiinued  consuinpiion  of  milk  trmn 
tuberculous  cows,  no  evil  consec^uences  followed  (Gallaverdin,  and 
the  cases  referred  to  by  A.  Weber,  of  Sermasi,  Joergen,  Stowell). 

A.  Hess,  while  pursuing  his  investigations  on  New  York  milk 
containing  lo  per  cent,  tubercle  bacilli,  found  that  some  of  the 
children,  who"  had  drunk  raw  milk  containing  bacilli,  on  being 
examined  a  vear  laier  were  in  good  healih  ;  a  fourth  of  these  on 
being  tested  gave  a  positive  reaction,  bin  doubt  exists  whriher  it 
was  due  to  the  bovine  type  of  tuberculosis. 

As  a  proof  bevond  (|uesiit)n  of  the  conveyance  of  bovine  tuber- 
culosis bv  infected  milk  the  following  is  instructive — Watt's 
obser\ation.  In  a  farm  only  inhalMted  in  simimer  by  three 
children  free  from  any  inherited  disease,  two  died  of  meningitis 
and  mesenteric  tuberculosis  after  the  consumjDtion  of  milk  from 
a  cow  alTected  by  general  tuberculosis  and  tuberculosis  of  the 
udder;  in  one  case  (which  is  quoted  by  Weber)  the  character  of 
the  disease  was  established  ;  further,  there  are  two  cases  by  Fibiger 
and  Jensen — Case  ii,  and  especially  Case  12.  A  little  girl,  aged 
i^,  coming  of  a  healthy  family,  died  of  severe  tuberculosis  of 
the  glands  of  the  intestines,  mesentery,  pharynx,  and  neck  after 
feechng  for  about  a  vear  on  raw  milk  from  a  very  tuberculous  herd 
of  cattle,  from  which  shorllv  before  a  cow  suffering  from  general 
tuberculosis  and  tuberculosis  of  the  udder  had  been  removed  and 
slaughtered. 

We  mav  mention  here  the  observation  of  \\"eber,  in  Giessen  : 
a  woman,  aged  29,  during  the  last  two  }ears  had  lived  partly  upon 
raw  milk  from  a  cow  undoubtedly  tuberculous;  in  her  case  tuber- 
culosis in  the  mouth  was  shown  by  Kossel  to  be  of  bovine  origin. 

.M(jnsarral  tells  of  a  district  of  7,000  to  8,000  inhabitants 
which,  from  1894-1898,  derived  its  milk  from  very  tubercuif)us 
cows  (thirt}--one  out  of  thirty-six  being  tuberculous).  The 
nimiber  of  children  under  15  d}'ing  of  abdominal  tuberculosis  was  : 
from  1891-1894,  9;  1895-1899,  38;  1900-1907,  S. 

The  scarcity  of  reliable  obser\alions  of  this  Ivind  dej^ends 
parll}-  upon  the  difficulty  of  establishing  subsecjuently  when  a 
disease  attacks  man,  the  previous  consumption  of  milk  that  \vas 
perhaps  infected,  and  the  source  whence  it  came. 

Collective  Investigation. — The  danger  of  drinking  milk  con- 
taining lu1)crcle  bacilli  has  been  tested  from  another  side.  On 
Koch's  initiative,  cases  of  proved  tuberculosis  of  the  udder  of  cows 
were  sought  out,  and  then  inquiries  were  made  as  to  how  long  the 
disease  had  lasted  and  what  people,  especiallv  children,  had  for 
some  time  taken  the  infected  milk  or  butter,  whether  and  how  the 
milk  was  cooked,  and  what  people  had  beer,  taken  ill. 


GliNliSIS     (>\-     SCKOl'LLOSIS  1J3 

Weber  inloniis  us,  ;ilici  iii\  csl igalifjiis  lasting  over  eigiii 
years,  and  noL  even  lln-n  conipliicd,  ilial  113  cases  were  collected; 
of  these  there  were,  (xj  in  which  raw  nnik  of  COWS  suffering 
from  tuberculosis  ol  ihc  udd<T  ov  pinducts  from  di<-  infecied  inilk 
(butter  and  cheese)  were  coiisiniifd  by  .l^o  ix-rsons  ((<(  wlioin  is' 
were  children)  during  a  l(^ng  period. 

Only  in  I  wo  faniilies  (in  e.'ich  one  cliikl)  could  an  inlcciion 
widi  bo\inc  (ubcrculosis,  namely,  lubercuhjsis  of  llie  neck  glands 
of  bovine  character,  be  established  with  certainly;  in  boHi  cases 
f(>eding  wilh  inleclcd  milk'  coniimicd  from  iIm-  lime  of  weaning, 
and  lasted  from  cnie  }ear  to  one  year  and  a  half.  Besides  this, 
swelling  of  the  neck  glands  occurred  in  six  children  and  one 
adult  ;  in  four  other  children  and  one  adull  suspicion  c^f  abdominal 
tuberculosis  occurred,  InU  "  disappeared  "  !  Another  child  was 
reported  to  be  suffering  from  scrofulosis;  in  133  other  children 
and  151  adults  who  had  taken  milk,  said  to  be  cooked,  oi  a  cow- 
suffering  from  tuberculosis  of  the  udder,  or  had  talcen  mixed  milk 
(in  the  form  of  butter)  of  many  cows,  tw-elve  children  and  one 
adult  showed  swelling  of  the  cervical  glands. 

It  cannot  be  denied  that  these  results,  in  \-iew  of  the  pro- 
nounced and  long  continuing  opporlimity  of  infection,  appear 
surprisinglv  insignificant,  even  when  we  reckon  all  doubtful  cases 
as  tuberculous  and  of  bovine  origin. 

The  collective  investigation  proves  that  the  bovine  bacillus  in 
childhood  is  frequentlv  non-^•irulent  or  only  slightlv  virulent. 

These  researches  naturally  do  not  prove  that  in  spite  of  them 
a  number  of  persons,  unknown  to  us,  mav  have  had  tuberculous 
mesenteric  glands  without  any  evident  indication,  and  which,  in 
accordance  with  the  slight  pathogenic  nature  of  the  bovine  tvpe, 
after  some  time  disappeared  spontaneouslv. 

In  the  same  way  many  small  foci  in  the  neck  glands  mav 
have  escaped  observation.  That  does  not  alter  the  fact  of  the 
circumscribed  virulence  of  the  bovine  bacilli ;  but  for  the  under- 
standing of  scrofulosis,  and  especially  for  the  interpretation  of 
apparently  motiveless  cutaneous  reaction,  we  must  keep  in  mind 
its  possibility,  and  even  its  probabilitv. 

Unfortunately,  at  that  time  v.  Pirquet's  reaction  was  not 
known ;  this  would  doubtless  have  given  us  manv  interesting 
disclosures. 

The  Difficulties  of  Intestinal  Infection. — The  reason  of  the 
relative  infrequency  of  distinct  infection  rests  partlv  on  the  fact 
that  the  intestinal  tract  is,  of  all  the  organs  of  the  bodv,  the  least 
accessible  to  a  tuberculous  infection  of  either  bovine  or  human 
bacilli. 


114  SCROFULOSIS 

Tluis,  for  example,  Findel  found  thai  by  inoesling  ig,ooo  to 
382,000  tubercle  bacilli  ihe  animals  did  not  become  tuberculous, 
wliile  twentv  bacilli  l)v  inhalation  were  sufficient  to  produce  tuber- 
culosis; after  further  experiments,  he  concluded  that  the  minimimi 
fatal  dose  in  ingestion  is  about  six  million  times  greater  than  the 
mininuirn  fatal  dose  in  inhalation. 

■  Accortling  to  L£\.ifert,  a  single  ingestion  of  40,000  bacilli  and 
a  repeated  dose  of  altogether  1,200,000  in  guinea-pigs  produces 
no  iiiheriiilosis ;  a  t  wd-millionth  part  of  the  dose,  which  in  the 
intestine  produced  no  tuberculosis,  is  suflicient  to  produce,  by 
inhalation,  a  most  severe  lung  tuberculosis  (see  also  Kuss  and 
Lobstein's  researches).  In  rabbits,  according  to  Alexander,  an 
ingestion  ()f  5  mg.  of  bacilli  of  human  type  repeated  six  times  had 
no  result  ;  an  ingestion  of  even  10  mg.  of  bovine  bacilli  repeated 
five  times  crave  a  doubtful  result  ;  whereas  inhalation  of  2>ooo  to 
50,000  bacilli  of  human  t\pe,  and  of  too  of  bo\ine  t\pe,  had  a  very 
decided  result. 

Similarlv,  according  to  Reichenbach,  who  attaches  special 
importance  to  the  repetition  of  infection,  guinea-pigs  become 
tuberculous  after  inhalation  of  three  doses  of  3  mg.  tubercle 
bacilli,  and  after  ingestion  of  o"02  mg.,  repeated  fifty-one  times, 
which  e([uals  i '02  mg.  (see  also  pp.  102-3).  Weber  and  Titze 
showed  in  cattle  that  for  infection  by  ingestion  at  least  10  mg. 
bovine  bacilli  are  necessary,  while  injection  by  inhalation,  with  a 
thousand  times  fewer  (100  mg.),  succeeded.  The  difference  is 
reallv  greater,  for  in  the  case  of  bacilli  spraved  for  inhalation  onlv 
a  very  small  number  get  access  to  the  deep  recesses  of  the  lungs 
in  inspiration. 

V.  Behring  has  repeatedly  referred  to  the  researches  of  \^allee, 
according  to  wliom  tuberculosis  in  cattle  is  easily  obtained  by 
ingestion,  but  with  inhalation  is  obtained  with  difficulty,  or  not  at 
all.  But  these  researches  are  not  of  much  value;  for,  as  vSpronck 
remarked  at  the  Fifth  International  Conference  on  Tuberculosis, 
in  these  ingestion  experiments  milk  of  a  cow  suffering  from 
tuberculosis  of  the  udder  was  employed,  therefore  quite  virulent 
material  ;  for  the  inhalation  experiments,  on  the  other  hand,  he 
employed  a  pure  culture  of  bovine  bacilli  cultivated  for  a  period 
of  ten  years  in  the  laboratory,  and  so  a  material  of  very  doubtful 
\iru1ence.  Therefore,  without  doubt  the  intestinal  tract  is  verv 
difficult  to  infect. 

Weber,  Fliigge,  and  Oslermann  conclude  from  this  that,  for 
infection  of  the  digestive  canal,  repeated  ingestion  of  an  immense 
number  of  bacilli  is  often  needed — a  number  which  usually  is  not 
found    in    shop   milk,    or  butter   made    from    such    milk.     But    I 


GENESIS   01-"   s(:roi(  i.osjs  115 

consider  ilic  (lc(|ii(  I  iciii,  ili.'il  icpi-i  ii  ion  plaws  an  iinportani  jjart 
anti  is  more  (•ric(li\c  ilian  wlicn  llic  wIujIc  {|iiantily  is  <^\\('.n  all 
in  one  dost",  is  nol  pro\cd  (sec;  also  Rciclicnhacirs  researches). 
Why  should  llie  repealed  adminisi  ralion  iiirn  ilie  scale?  Must 
we  then  conclude  dial  die  next  bacillus,  or  next  but  on(*,  that  is 
inoculated  lakes  ex:i(  liv  die  same  sjxtt  for  ils  point  oi  attack  in 
die  enorniousK-  large  inieslinal  siirla<e  as  ils  |)redecessors,  or 
by  die  earlier  introduction,  which  was  inefTecli\e,  the  whole  body, 
or  at  least  the  whole  intestinal  canal,  is  so  altered  that  it  is  much 
more  receptive  for  die  fiirllier  intj^eslion  of  the  bacilli?  Xeiiher 
the  (jne  nor  the  other  is  proved  or  probable;  on  the  contrary, 
perhaps  we  may  rather  suppose  that  a  certain  protective  effect  has 
been  obtained. 

The  frecjuent  introduction  of  a  small  c|uantity  will  hardly  be 
likelv  to  make  infection  more  probable  than  the  introduction  of 
the  same  quant it\-  all  at  once.  In  the  Franco-German  war,  as  is 
well  known,  according  to  statistics,  there  were  about  1,000  dis- 
charged bullets  to  only  one  wound;  but  it  would  not  enter  into 
anyone's  head  to  sav  that  a  battle  in  which  100,000  shots  were 
fired  was  less  dangerous  than  ten  battles  each  with  10,000 
bullets. 

According  to  mv  A-iew,  some  researches  which  I  made  some 
years  ago  are  of  interest,  even  if  their  small  number  (I  think  it 
was  six)  do  not  make  them  conclusive. 

I  kept  guinea-pigs  without  food  so  that  the  intestine  was  at 
rest.  In  consequence  a  much  smaller  quantity  of  tubercle  bacilli 
was  sufficient  for  infection  of  the  intestine  tlian  without  this 
preparation  beforehand.  Unfortunately,  I  have  lost  count  of  the 
exact  number  of  bacilli  used.  This  much  appeared  to  me  evident, 
that  the  severity  of  infection  does  not  lie  in  the  insusceptibilitv  of 
the  intestinal  mucous  membrane,  but  in  the  quick  passage  of  the 
infected  material,  which  does  not  allow  the  bacilli  to  get  a  tirm 
hold  or  to  settle,  and  also  in  the  mixing  with  the  intestinal 
contents  and  in  the  Malpighian  laver  which  covers  and  protects 
(see  also  Cornet,  "  Die  Tuberculose,"  second  edition,  p.  235). 

Conclusions. — If  we  collect  our  experiences  it  is  certain  that 
only  a  comparatively  small  number  of  effective,  manifest  infec- 
tions, and  those  almost  exclusively  in  children,  are  due  to  the 
enormously  numerous  opportunities  of  bovine  infection  in  the 
alimentary  canal ;  the  reason  for  this  lies,  on  the  one  hand,  in  the 
relative  difficulty  of  tuberculous  infection  of  the  intestine,  but  more 
especially  in  the  circumstance  that  bovine  bacilli  are  almost 
avirulent  for  adults,  and  are  only  virulent  for  children  to  a 
modified    degree,    only    very    seldom    producing    a    pronounced 


I  10  SCROFLLOSIS 

tuberculosis  (such  as  ofien  occurs  in  scrofulous  glands),  and  still 
less  often  leading  to  a  progressive  tuberculosis. 

Small  as  is  the  danger  in  individual  cases,  the  multiplicity  of 
opimriunitit'S  gi\es  it  ctuisidt  rable  importance  for  children. 

Skin  Infection  through  Bovine  Bacilli. — Bovine  bacilli  mav 
often  take  a  part  in  the  infections  caused  by  lilth,  which  often 
lead  to  scrofulosis  only  in  consequence  of  the  anatomical  difference 
of  the  skin;  the  clinical  effects  are  distinct  from  the  skin  affections 
of  adults  previoush-  mentioned  (see  pp.  64  and  80). 

Tuberculous  skin  affections  and  lupus  have  been  recorded  by 
Leloir,  Grothan,  Priesler-Heller  after  fomentations  with  raw  milk 
and  cream,  which  are  customary  among  the  loAver  classes.  Such 
infections  and  glandular  swellings  in  the  neck,  for  example,  can 
arise  from  the  mucous  membrane,  especially  in  children,  without 
visible  primary  affection  at  the  site  of  origin. 

Infection  of  the  Lungs  and  Bronchial  Glands  by  Bovine  Bacilli. 
— Besides  the  digestive  tract  and  the  skin,  milk  containing  tubercle 
bacilli  and  other  dried  materials  containing  bovine  bacilli  can  dry 
up,  pulverize,  or  spray,  and  become  a  source  of  danger  to  the 
respiratory  organs  and  bronchial  glands,  just  as  well  as  human 
bacilli. 

Such  a  drying  up  and  dispersal  is  as  little  to  be  contested  as 
a  casual  infection  by  the  inhalation  of  such  bovine  bacilli,  "  for 
after  much  rain  one  gets  wet  at  last." 

Latent  Foci. — The  entry  of  a  small  quantity  of  bovine  bacilli 
into  the  respiratory  organs  does  not  cause  any  progressive  tuber- 
culosis. On  account  of  their  low  pathogenic  nature  either  no 
change  occurs  in  the  lungs  and  the  bronchial  glands  and  the 
bacilli  die  away  after  a  time;  or  small  lymphoid  foci  form,  with 
no  tubercle  formation,  such  as  Bartel  occasionally  found  in  his 
interesting  experiments  on  animals;  in  both  cases,  however,  the 
further  inoculation  of  such  organs  into  guinea-pigs,  which  are 
highly  receptive,  after  a  long  time  has  elapsed,  produces  a  perfectlv 
characteristic  tuberculosis,  a  fact  which,  although  all  the  bacilli 
have  died  off,  has  given  rise  to  the  most  remarkable  hypotheses 
on  latent  inducement.  Or  a  large  sv/elling  of  the  affected  bron- 
chial glands,  or  perhaps  the  nearest  glands,  occurs;  clinical 
phenomena  appear,  identical  with  those  w-hich  we  will  describe 
further  below  as  symptomatic  of  scrofulosis  of  the  bronchial  glands  ; 
finally,  a  spontaneous  retrograde  metamorphosis  occurs,  the  foci 
harden  and  become  chalky,  but  are  evidenced  for  vears,  even 
decades  after,  by  allergic  and  by  positive  cutaneous  reaction  to 
tuberculin. 


(JKNKSIS     OF    SCKOJ-LLCjSIS  II7 

J'osL  iiLorLciii,  siK  li  ln(  i  in  ilic  lungs,  broiicliial  and  mesenteric 
glands,  proclaim  I  he  (hoxinc)  tuberculous  processes  which  had 
formerly  taken  place  years  .iiid  dfindcs  l.-iKr  l)\-  chalk,  exactly 
like  completely  healed  foci  ol  liuni;in  ba(  illi,  but  which  probably 
run  so  favour.'ible  a  course  much  more  rarely.  It  is  probably 
these  foci  which  have  often  deceived  Xaegeli  and  his  numerous 
followers  in  their  studies  of  latency  and  which  exactly  answer 
to  those  we  liave  obtained  l)y  doing  llie  reverse,  viz.,  inj(M;ting 
calves  with  human  bacilli. 

As  it  is  just  the  so-called  Xaegeli  foci  which  ha\e  led  to  the 
formation  of  hypotheses  which  are  far  reaching  but  erroneous, 
it  appears  1(j  me  most  instructive  to  add  for  compariscjn  extracts 
from  the  findings  of  Kossel,  Weber,  and  lleuss  in  the  subcu- 
taneous injection  of  human  bacilli  into  cahes,  for  which  animals 
they  are  only  slightly  virulent,  because  thev  give  us  at  the  same 
time  a  survey  of  what  may  be  expected  in  man,  in  case  of  incipient 
bovine  infection,  \\hich  is  important  also  for  scrofulosis.  1  recom- 
mend them  especially  to  the  notice  of  those  investigators  for 
whom  a  long  latency  of  the  tuberculous  foci  is  an  axiom,  and 
a  very  chalky  focus  only  the  expression  of  an  individuallv  defec- 
tive disposition,  while  actually  only  the  general  insusceptibility 
of  man  for  that  certain  type  of  bacillus  is  much  more  frequently 
the  cause. 

Naturally  one  must  bear  in  mind  that  in  Kossel's  researches 
in  cattle  infinitely  many  more  bacilli  were  injected  than  would 
have  penetrated  in  the  case  of  natural  infection  in  man,  and  this 
would  cause  the  extensive  though  transitorv  changes  at  the  site 
of  injection,  which  w^ould  be  partly  compensated  bv  the  fact  that 
cattle  in  general  are  much  less  susceptible  to  human  strain  than 
are  children  to  bovine  strain. 

H2. — Prescapular  gland  after  four  weeks  the  size  of  a  goose's 
egg  ;  after  three  months  not  any  larger ;  after  139  davs  in  cattle 
a  chalky  deposit  the  size  of  a  pea. 

H3. — Prescapular  gland  after  seven  weeks  the  size  of  a  hen's  egg; 
not  an}'  larger  after  three  months;  no  change  after  121  davs, 
but  induces  tuberculosis  when  injected  into  guinea-pigs. 

H4. — Prescapular  gland  for  a  long  time  the  size'  of  a  goose's  egg, 
then  of  a  hen's  egg;  after  121  davs  two  foci  the  size  of  a 
hazel  nut  of  yellowish  ilocculent  pus,  or  a  chalkv  deposit  the 
size  of  a  peppercorn  in  the  gland  tissue. 

Further  in  the  low  neck  glands  a  small  cheesv  mass  the 
size  of  a  bean ;  in  a  second  beast  in  the  prescapular  gland 


Il8  SCROFULOSIS 

after  159  days  one  the  size  of  a  pea,  one  llie  size  of  a  hazei 

nui.  and  two  also  the  size  of  a  hazel   nut,   with  casetuis  and 

ehalkv  contents. 
II9. — Prescapular  gland  after  fourteen  days  the  size  of  a  goose's 

egg;  after  two  inonihs  the  size  of  a  walnut;  after   130  days 

two  cheesy  "deposits  the  size  of  a  lentil  bean. 
11 10. — Site  of  injection,  after  three  weeks  the  size  of  a  hen's  egg; 

after  two  and  a  half  only  a  slight  thickening;  after   i7()  days 

onlv  thickening  of  the  connect i\e  tissue. 
II 13. — Prescapidar  gland  after  fourteen  days  almost  the  size  of  a 

goose's  egg;  after  six  weeks  the  size  of  a   hen's  egg;  after 

130  days  two  foci  the  size  of  a  pea,  formed  1)\    the  union  of 

a  number  of  cheesy  nodules. 
H15. — Site  of  injection  after  six  weeks  a  swelling  the  size  of  a 

goose's  egg;   softening;  after   six   months   slight    thickening 

of    connective    tissue,     with    numerous    cheesy    and    chalky 

deposits,  which  had  a  virulent  effect  on  guinea-pigs. 
H21. — -Prescapular  gland  after  three  weeks  the  size  of  a  goose's 

egg,   then  smaller;  after  203  da\s  unchanged;  produces  no 

tuberculosis  in  guinea-pigs. 
FI22. — Site  of  injection,  after  143  davs,  thickening  c)f  connective 

tissue,  with  two  cheesy  deposits  the  size  of  a  pea. 

Prescapular  gland  after  fourteen  days  the  size  of  a  goose's 

egg;  after  three  and  a  half  months  no  larger;  after  143  days 

a  cheesy  focus  the  size  of  a  hemp  seed  under  the  capsule. 
H23. — Prescapular  gland  after  fourteen  days  the  size  of  a  hen's 

egg;  after  two  and  a  half  months  hardly  any  increase  in  size; 

after  176  days  focus  only  perceptible  by  its  changed  colouring  ; 

apparently  healed  tuberculosis,  but  capable  of  infecting  ^^•hen 

injected. 
H25. — Prescapular  gland  after  four  week's  the  size  of  a  goose's 

egg;  after  three  and  a  half  months  the  size  of  a  pigeon's  egg; 

after  133  days,  at  each  extremity,  a  cheesy  mass  the  size  of 

a  hazel  nut;  besides  which,  the  intermediate  cervical  glands 

were  the  size  of  a  bean,  with  a  caseating  chalkv  focus;  the 

lower  cervical  glands  were  also  enlarged,  but  without  infective 

properties. 
H26. — Prescapular  gland  after  fourteen  days  the  size  of  a  goose's 

egg,   then  a  retrograde  formation  ;  after   130  davs  a  chalky 

mass  the  size  of  a  millet  seed. 
H28. — Prescapular  gland  after  fourteen  days  the  size  of  a  hen's 

egg;   later  no   increase  in   size;   after   125   days  a   vellowish 

focus  the  size  of  a  peppercorn,  \vhich  produced  tuberculosis 

in  guinea-pigs. 


(iKNKSlS     OF    SCKOI'CLOSIS  II9 

II31. — Prc.sca[)ular  j^laiul  alicr  toiirlcen  days  llie  size  ot  a  lien's 
egg;  later  ol  noiinal  size;  alier  136  days  showed  a  yelUnv 
cheesy  mass  ihc  si/c  nl  :\  Icniil  hc'in,  besides  three  cheesy 
n(jdules  in   llic  nemcsl   ((•r\i(al  ^h'lnds. 

II33. — Prescapniar  inland  allcr  tonr  weeks  I  he  size  of  a  hen's  egg; 
alter  i.'^i  days  contained  a  chalky  mass  as  large  as  a  good- 
sized  pea,  besides  several  small  chnlk-y  masses  the  size  nf  a 
millet  seed  or  a  i:)eppercorn. 

II40. — Prescapular  gland  after  ten  days  the  size  oi  a  goose's  egg; 
after  two  and  a  half  monliis  the  size  of  a  hen's  (tgg\  after  120 
days  a  scar  in  the  connective  tissue  the  size  of  a  hemp  seed, 
and  a  caseous  chalk'\'  mass  the  size  of  a  pea  or  a  hemp  seed. 

We  often  find  similar  foci,  even  if  less  pronf)unced,  in  rabbits 
which  have  been  subculaneously  injected  with  the  human  bacillus. 
In  view  of  the  reduced  virulence  of  the  bovine  bacillus  in  adults 
and  even  in  children  on  the  one  hand,  and  the  ninnerous  oppor- 
tunities of  infection  with  the  bovine  bacillus  on  the  other  hand, 
such  old  bovine  foci  will  be  frequently  found  in  the  cadaver  of 
children,  and  as  such  chalky  masses  endure  for  a  long  time 
similar  chalky  deposits  are  necessarily  and  certainlv  found  also 
in  adults. 

What  Naegeli  and  Schlenker,  Burckhardt,  6cc.,  who  also 
studied  these  latent  foci,  found,  only  by  the  most  painstaking 
investigations,  were  small  cheesy  foci  in  the  lungs  and  the 
bronchial  glands  and  small  chalky  deposits.  Naegeli,  for  instance, 
found. a  "  tiny  yellowish-green  nodule  below  the  apex  of  the  lung 
hardly  the  size  of  a  pin's  head,  small  pleuritic  scars,  and  in  a 
tracheal  gland  some  yellowish-grey  suspicious  nodules  with 
caseation,  giant  cells,  tubercle  bacilli,"  &c. 

In  view  of  the  possibility  that  such  foci  are  caused  bv  bovine 
or  human  bacilli  it  was  necessary  for  Xaegeli  to  prove  first  that 
his  foci  were  of  human  origin,  therefore  capable  of  full  develop- 
ment and  having  a  progressive  tendencv,  before  he  deduced  from 
them  the  much  greater  importance  of  the  disposition  of  the  bodv 
than  of  the  possibility  of  infection  and  soared  to  the  serious  but 
happily  false  statement  that  "  every  adult  is  tuberculous." 

If  Naegeli 's  foci  were,  as  must  be  supposed,  for  the  most  part 
of  bovine  and  similar  nature  which  had  spontaneouslv  become 
calcified  and  had  no  further  powers  of  development,  the  cause 
of  this  lies  in  the  generally  lessened  pathogenic  nature  of  this 
type  for  men,  and  not  in  the  increased' power  of  resistance  of 
single  individuals,  and  thus  all  the  conclusions  drawn  from 
Naejjeli's  results  fall  to  the  eround. 


120  SCROFULOSIS 

C.-AVIAN  TYPE. 

Man  appears  not  to  be  threatened  by  avian  tuberculosis  to 
anv  appreciable  degree. 

Kruse  and  Pansini  have  mentioned  the  cultivation  of  bacilli 
from  human  sputum  which  Ijehaved  in  the  same  manner  as  avian 
tubercle  bacilli.  Further,  Joncso,  and  I^lfer,  Lowenstein,  L. 
Rabinowitsch,  each  found  the  avian  type  in  one  case;  how  far 
this  had  to  do  with  mixed  infection  remains  uncertain. 

If,  however,  by  means  of  the  avian  type  no  progressive 
tuberculosis  is  produced,  the  possibility  is  not  excluded  that  small 
foci  spontaneously  retrograding  are  formed  at  the  site  of  injec- 
tion and  the  nearest  gland.  L.  Rabinowitsch  has  many  times 
found  avian  tuberculosis  in  apes  (animals  usually  not  susceptible 
for  avian  type),  and  de  Haan  has  produced  fatal  tuberculosis  by 
inoculadng  them. 

111.— THE    DIFFERENT    EFFECTS    OF    THE 
INFECTION. 

Experiments  on  animals  have  in  many  cases  enlightened  us 
as  to  the  reasons  why  in  scrofulosis,  and  in  infection  generally, 
when  the  bacteria  are  brought  into  contact  with  the  skin  or  mucous 
membrane,  in  one  case  they  produce  changes,  why  in  another  case 
they  pass  by  leaving  no  traces  and  only  develop  in  the  glands, 
and  why  in  a  third  case  they  affect  both  kinds  of  tissue  sympatheti- 
cally. This  different  effect  depends  on  (i)  the  tissue;  (2)  the 
nature  of  the  micro-organism  ;  (3)  the  closeness  of  the  contact. 

(i)  The  Histological  Nature  of  the  Tissue. — The  closer  the 
formation  of  the  tissue  the  greater  difficulty  have  the  bacteria  in 
passing  through  it,  and  the  more  easily  are  they  held  back 
entirely  or  in  part  in  a  dense  tissue;  ceteris  paribus,  the  bacteria 
are  only  conveyed  if  the  continuity  is  disturbed  either  before,  or 
by  the  process  which  has  been  induced.  The  mucous  membrane 
lets  bacteria  pass  through  rnore  easily,  while  the  cutis  is  more 
prone  to  retain  them.  It  has  been  found  much  more  easy  in 
experiments  to  introduce  bacilli  into  the  mucous  membrane  of 
the  mouth  and  nose  and  so  to  the  glands  without  introducing 
local  changes  at  the  point  of  entry,  than  in  the  skin,  where  it  has 
hardly  ever  been  done  without  local  injury. 

The  influence  of  direct  injury,  epithelial  abrasions,  &c.,  will 
be  spoken  of  later. 

State  of  Nutrition  of  the  Tissues.— When  the  skin  is  saturated 
and  bathed  to  excess  with  nufrilive  fluids,  as  is  the  case  in  young 


GENESIS    Ol-     SCKOI'UUJSIS  I2J 

pasty  individii.'ils,  llu'  hac  Icri.'i  at  uiicc  liiid  an  inlinilcly  rif;licr 
nutnlivc  maicrial  than  wIkii,  especially  in  older  pf^ople,  it  is  dry 
and  poor  in  l\in|)li. 

(2)  The  Size  of  the  Micro-organisms.  I  Ik-  larger  ilie  baeuria 
are  llie  grealcr  (IUVkiiIiv  lia\c  liny  in  pcnci raling,  and  the-  more 
easily  are  lliey  retained,  a  siniplr  physical  circumstance  which  is 
usually  quite  neglected;  that  tubercle  bacilli  are  much  smaller 
than  pus  cocci  is  well  known. 

Biological  Chafacters.  Single  bacteria  which  have  been 
retained  in  llic  skin  bv  (heir  slow  growth,  which  is  characteristic 
of  the  tubercle  bacillus,  arc  much  uKjre  easily  and  completely 
eliminated  by  the  ciliated  epithelium  and  mucous  exudations  than 
other  bacteria  which  have  great  power  of  proliferation  even  at  a 
low  temperature;  these  increase  so  freely  in  a  few  hours  that  even 
if  a  part  is  expelled  at  the  surface  a  complete  elimination  does 
not  occur  and  those  remaining  behind  in  the  lymph  spaces 
proliferate  and  are  distributed  farther.  Only  by  reactive  tissue 
irritation,  inflammation  or  gradual  using  up  of  the  material  can 
the  body  rid  itself  delinitelv  of  them.  The  relative  infrequency 
of  tuberculosis  of  the  skin  (lupus,  &c.),  and  the  frequency  of 
non-tuberculous  pyogenic  scrofulous  skin  affections  of  various 
kinds  is  owing  to  this. 

The  Number  of  the  Bacteria. — This  acts  in  the  same  way  as 
the  biological  conditions.  Isolated  bacteria  pass  through  the 
mucous  membrane  much  more  easily,  and  all  reach  the  glands; 
but  in  large  collections  a  part  is  more  likely  to  be  held  back. 
By  a  sufficiently  close  contact  of  the  mucous  membrane  of  the 
eye,  mouth,  and  nose  wath  many  tubercle  bacilli  local  changes 
never  failed  to  appear  which  advanced  to  the  stage  of  ulceration 
(tuberculosis  of  the  glands  did  not  appear) ;  on  the  other  hand, 
with  scanty  infection,  local  changes  were  not  exhibited,  and 
tuberculosis  of  glands  resulted. 

Virulence. — Ceteris  paribus,  slightlv  virulent  germs,  as  well 
as  benign  foreign  bodies,  carbon  particles,  or  granules  of  colouring 
matter,  are  more  easily  conducted  to  the  glands  than  highlv 
virulent  bodies,  which,  by  their  vigorous  growth  and  virus, 
immediatelv  set  up  a  tissue  irritation. 

(3)  The  Closeness  of  Contact — In  the  skin  with  no  external 
injury  a  simple  laying  on  of  bacteria  is  absolutelv  without  anv 
ill  result. 

Only  with  tolerably  violent  friction  did  I  succeed  during  mv 
numerous  experiments  in  directing  the  bacilli  to  the  glands 
without  producing  local  changes,  except  a  tinv  scale,  the  character 
of    which    was    questionable.      On    the    other    hand,    with    hard 


122  SCROFLLOSIS 

t'riciion,  ulceraiimi  or  lupoid  cliani^es  constanily  occurs,  but  in 
this  case  the  full  inicgriiy  oi  the  skin  is  no  longer  assured. 

In  mucous  menihranes  an  infection  residts  much  more  easily. 
It  is  true  there  is  in  this  case  a  simple  and  transitory  contact 
vvitlu)ut  further  consei|uences  (protective  mucous  covering"),  hui 
just  as  the  bacilli  settling  in  the  alveoli  of  the  lungs  can  penetrate 
like  the  particles  of  larhon  inio  ilu-  mucous  membranes,  so  did 
thev  succeed  in  obtaining  a  transmission  to  the  glands,  with  con- 
sequent gland  tuberculosis,  while  the  integrity  of  the  mucous  mem- 
brane was  retained;  in  the  case  of  the  coniuncli\al  sai-  and  \agina 
bv  a  simple  deposit,  and  in  the  case  of  the  other  mucous  mem- 
branes hv  slight  rubbing  with  a  very  small  quantity  of  bacilli. 
In  the  intestine  the  peristaltic  movement  alone  with  a  vevy  scanty 
quantitv  of  material  is  enough  to  produce  infection,  and  with  a 
larger  c|uantitv  of  material  infection  is  produced  in  the  mucous 
membranes  and  in  the  glands. 

It  is  onh'  by  carefully  weighing  all  these  facts  that  we  can 
come  to  a  full  understanding  of  the  infection, 

IV.— THE  DISPERSAL  OF  TUBERCULOUS      . 
INFECTION- 

The  Ivmphalic  glands  and  the  Ivmph  s\"stem  plav  an  impor- 
tant part  in  the  dispersal  of  tuberculosis  from  the  point  of  entry. 

M\-  experiments  on  animals  have  shown  that  after  subcu- 
taneous injection  in  the  region  of  the  abdomen,  at  the  end  of 
from  three  to  live  weeks  the  following  exhibit  macroscopic 
changes  in  the  descending  scale  as  to  size  and  extent  :  the  glands 
around  the  iliac  vein,  lumbar  glands,  splenic  and  porta!  glands, 
and  those  of  the  li\-er,  then  the  bronchial  and  pulmonary,  which 
both  exhibit  slight  changes;  in  the  further  course  of  infection 
the  cervical  glands  often  become  involved* 

Weleminskv,  wlio  has  studied  the  question  on  a  large  number 
of  animals  (i,ooo),  arrives  at  similar  results,  namely,  th.e  inguinal, 
iliac,  lumbar  glands  and  so  on  ;  he  emphasizes  at  the  same  time 
the  fact  that  after  the  glands  in  ihe  area  of  infection,  the  Ivmph 
glands  leading  to  the  bronchial  glands  are  affected,  then  the 
bronchial  glands  themselves. 

Westenhoeffer  (Ijy  experiments  on  120  guinea-pigs)  confirms 
this  course,  apparently  without  knowing  of  my  experiments, 
which  are  sixteen  years  older  and  thirty  times  more  extensive. 
Beitzke,  bv  experiments  on  150  animals,  gives  the  order  as: 
inguinal,  iliac,  and,  later,  the  bronchial  glands. 


GENESIS    OF    SCROI-ULOSIS  1 23 

()clilc(k-cr  describes  Lhc  course  as  ab(juL  llic-  same,  n;iiiM-ly, 
in^uin.'il,  p.-ira-iliac  (retroperitoneal,  Tendeloo's  para-aortal,  aho\<- 
the  kidneys,  wliicli  Weleminsky  describ(;s  as  middle  or^^anj,  then 
the  portal  jj^lnnds  ;  llie  Iraclieo-broncliinl  ^dnnds  are  at  first  fmly 
slightly  allocked  or  nol  al  .'ill;  in  (lie  spleen  a  few  nodules  occur, 
the  portal  glands  become  caseous,  and  lat(;r  the  liver  is  involved; 
simultaneously  or  later,  pulmonary  tuberculosis  with  considerable 
enlargement  of  the  Iraclieo-broncliial  glands  sets  in;  ih<-n  the 
para-aortal  glands  are  attacked,  iliac  glands  of  the  op|)(»site  side 
and  r(Mrogressi\'el\-  llie  inguinal  glands  of  the  other  side. 

In  the  main,  therefore,  the  infection  ot  the  glands  follows 
the  course  of  the  lymph-stream,  forming  a  chain  of  glands  like 
a  row  of  heads  which  gets  smaller  as  it  approaches  the  centre; 
it  extends  from  the  place  of  infection  in  a  circumsi  ribed  manner 
as  the  process  radiates,  on  account  of  the  numerous  anastomosing 
branches  which  connect  the  lymph-vessels  one  ^vith  another,  and 
now  and  again  it  extends  sideways  and  sometimes,  but  rarely, 
retrogrades  as  the  result  of  congestion;  the  germs  of  infectif>n  are 
all  the  more  forced  to  take  a  side  course  when  the  direct  paths 
are  more  or  less  obstructed  by  previous  processes  (see  p.  222). 

In  this  course  no  important  intervening  organ,  connected 
with  the  glands,  is  ever  passed  over,  tuberculous  glands  never 
appear  in  any  part  of  the  body  without  intermediate  steps.  It  is 
only  later  that  ha^matogenous  dispersal  takes  place. 

Weleminsky,  Westenhoeffer,  Bartel,  &c.,  share  this  opinion. 

When,  however,  AA^eleminsk_y  states  that  the  whole  of  the 
glands  unite  in  the  bronchial  glands,  and  when  he  attributes  to 
them  the  character  of  a  heart  for  the  whole  lymph  system,  he 
doubtless  goes  too  far;  he  must  stand  alone  in  his  opinion,  in 
which  he  has  been  strengthened  no  doubt  by  making  the  mistake 
of  using  human  bacilli  in  rabbits  (as  shown  by  Oehlecker,  see 
p.  100),  and  in  the  statement  that  organs  infected  h^ematogenously 
do  not  infect  their  glands.  But  I  must  agree  with  Weleminsky 
in  the  one  case,  that  in  subcutaneous  injections  in  the  region  of 
the  abdomen  the  chain  of  tuberculous  glands  can  be  traced  in 
their  proportionallv  decreasing  size,  often  as  far  as  the  bronchial 
glands  and  in  isolated  cases  even  farther ;  so  that  one  may  get 
the  impression  of  close  connection  between  the  conveving  inguinal, 
iliac  and  bronchial  glands;  the  spleen  and  liver  glands  are  usually 
attacked  before  the  lungs  and  the  bronchial  glands. 

It  is  the  same  in  inoculation  of  the  upper  portion  of  the  body, 
in  experiments  on  the  gums,  nose  or  ear,  after  a  few  weeks  a  chain 
of  glands  of  decreasing  size  goes  from  the  neck  glands  to  the 
bronchial    elands,    but   the   iliac  £?'lands,    &:c..    remain    free.     The 


124  SCROFULOSIS 

legitimate  path  of  the  bacilli  is  from  the  glands  to  the  thoracic 
duct  or  to  the  vein.  Now,  it  is  a  much  disputed  question  whether 
the  tubercle  bacilli  can  travel  directly  from  the  iliac  and  lumbar 
glands,  and  in  the  upper  part  of  the  body  from  the  neck  glands, 
into  the  Ivmph-vessels  directlv  to  the  bronchial  glands,  or  if  they 
must  take  the  recognized  path  through  the  blood-vessels  (see 
v.  Behring,  Harbitz,  Pottenger,  Weichselbaum,  Leroux,  Westen- 
hoeffer,  Karlinski). 

\\"eiglilv  anatomical  grt)unds  are  given  for  ihe  bK)od-vcssels 
as  the  only  path. 

Recently  extensive  researches  with  respect  to  the  lymph  pas- 
sages have  been  made  by  injection  into  living  animals  and  on 
dead  bodies;  in  these  investigations  great  credit  is  due  to  Most. 
We  abridge  his  account  as  follows. 

According  to  these  researches  the  whole  of  the  Ivmpli  of  the 
entire  human  bodv  meets  on  botli  sides  of  the  junction  of  the 
bulbus  jugularis  with  the  subclavian,  and  thus  : — ■ 

(i)  The  deep  cer\ical  lymph  glands  which  take  up  the  whole 
of  the  hiiiph  from  the  head  in  part  directlv,  and  in  part  by  means 
of  the  submental,  submaxillary  and  subaurvcular  glands,  the 
mastoid  glands,  the  pra^laryngeal,  pra?tracheal,  and  paratrachea! 
glands. 

(2)  The  interthoracic  Ivmph  passages,  namelv  :  — 

(a)  Those  of  the  tracheo-bronchial  region, 

(b)  Those  of  the  lungs, 

(r)  Those  of  the  retrosternal  Ivmpli  \essels,  and  on  ilie  left 
(d)  The  thoracic  duct. 

(3)  The  axillary  lymph  channels  flow  towards  the  above- 
mentioned  junction  through  the  truncus  subclavius. 

According  to  Most,  the  separate  lymph  areas  come  into  more 
intimate  local  connection  at  that  point;  but  he  considers  an 
exchange  of  lymph  in  the  different  areas  and  a  passing  over  of 
the  germs  from  one  region  to  another  impossible,  as  this  would 
presuppose  a  deficiencv  and  obliteration  of  the  valves,  which  lie 
close  together,  and  are  efficient  in  their  action.  According  lo 
anatomical  researches  a  change  in  the  direction  of  the  stream, 
a  forcing  back  or  straining  of  the  \alves,  could  not  be  obtained 
in  spite  of  forced  injection.  The  supposition  of  a  rel  re -grade 
passage  is,  therefore,  to  be  accepted  with  great  caution. 

According  to  ]\Iost,  there  is  no  proof  of  anv  connection 
between  the  lymph  vessels  of  the  cervical  Ivmphatic  region  and 
the  summit  of  the  pleura,  or  with  the  l^ronchial  glands;  the 
passage  to  those  regions  is  anatomicalK'  impossible,  a  regular  or 
even  a  frecjuent  transmission  is  not  lo  be  lliou^ht  of  (see  p.  103). 


GENESIS    OE    SCRUI'ULOSIS  I  25 

"All  we  can  hcUcvf  is,  lli.-ii  l)\  inmhiil  .-inatoniical  processfs  n(;v. 
passages  are  crealed,  m-  ilic  iiilcciioii  is  carried  by  conliguily 
from  gland  lo  gland,  from  gland  are.-i  lo  gland  area  "  (Most). 

Jieil/k-e,  basing  his  theory  on  researches  (jblained  by  infec- 
tion ot  the  dead  l)odies  of  children  and  guinea-pigs,  considers 
that  infection  of  the  iritratlioracic  glands  frfjm  liie  deep  cervical 
glands  is  impossi1)le,  and  denies  a  communication  between  the 
cervical,  mesenteric  and  relroslernal  glands.  Kitamura  lias 
arrived  at  the  same  results,  and  Albrecht  expresses  a  similar 
opinion.  But  against  this,  llenle  menti(jns  a  connection  of  (he 
lower  deep  cervical  glands  with  the  glands  of  the  axilla  and  the 
thorax  l)v  branches  which  run  in  dilferent  directions  and  act  as 
vessels  leading  to  and  from  them. 

In  the  lower  half  of  the  body  the  thoracic  duct  collects  tlu- 
lymph  of  the  abdominal  organs  and  the  lower  extremities.  1; 
consists  of  three  trunks  :  — 

The  right  and  left  lumbar  trunks,  which  have  their  confluence 
at  the  level  of  the  upper  lumlxir  vertebra,  and  which  the  intestinal 
trunk  joins.  The  lumbar  trunk  collects  the  lymph  of  the  pelvis 
and  of  the  lower  extremities  (external  and  inter-inguinal  glands), 
lumbar  glands  (about  the  iliac  vessels),  and  the  retroperitoneal 
glands  (or  para-aortal  glands  of  Tendeloo).  The  efferent  lymph 
vessels  leading  from  the  stomach  reach  the  retroperitoneal  glands. 

From  the  intestine  the  lymph  goes  into  the  mesenteric  glands, 
which  lie  in  several  layers  over  each  other,  and  then  to  the  radix 
mesenterica  and  the  retroperitoneal  glands,  which  also  receive  the 
lymph  directly  from  the  testicles  and  ovaries. 

Intestinal  infection,  therefore,  travels  by  way  of  the  mesenteric 
and  retroperitoneal  glands  and  the  duct  into  the  vena  cava 
superior,  the  right  heart,  pulmonary  arteries  and  the  lungs.  Xo 
other  passage  from  the  abdominal  organs  to  the  bronchial  glands 
exists  (Most,  Beitzke). 

How  can  the  results  of  the  experiments  on  animals  be  made 
to  agree  with  anatomical  facts? 

In  manv  cases  after-infection  mav  take  place  during  the  con- 
finement of  the  animals  bv  sporadic  germs  (from  ruptured  subcu- 
taneous places  of  inoculation,  Szc),  by  way  of  inhalation,  or  by 
swallowing  food  infected  with  the  germs;  the  swelling  of  the 
neck  and  bronchial  glands  thus  caused  can  give  rise  to  the 
illusion  that  the  Ivmph  glands  have  taken  a  course  contrarv  to  the 
anatomical  course. 

Doubtless  we  are  all  now  and  again  deceived  bv  such  results, 
which  are  difficult  to  be  avoided,  and  all  the  more  so  as  by  inhaling 
few^er  eerms  the  lune  itself  often  remains  free. 


126  SCKe)l-L  I.OSIS 

One  miglil  also  imagine  an  inspiration  ot  bacilli  which  have 
entered  the  mouth  into  the  deeper  air  passages,  as  Nenninger, 
Paul,  Ficker,  and  Bartel  especially  note;  but  these  authors  used 
such  drastic  methods  (deluging  the  mouth  with  cultures  of  pro- 
digiosus,  closing  the  wind-pipe  1)y  pressure,  <S:c.,  see  criticisms 
in  C\uiu't's  "  I^ie  Tuberculose,"  second  edition,  p.  295),  thai  no 
conclusions  on  natural  conditions  can  be  drawn  from  tlu-ni. 

In  the  experiments  of  Beitzke,  who  fed  animals  with  ciiliures 
of  Bacillus  proiiigiosus  and  killed  them  by  a  lilow  on  the  neck,  it 
might  have  been  the  stertorous  breathing  of  the  dying  animal 
which  caused  the  aspiration  (Aufrechi).  I  lulcr  naiural  conditions 
a  moderate  quaniiiv  of  bacilli,  introduced  inio  the  mouth  without 
artificiallv  inducing  laljoured  breathing,  cannot  enter  the  larynx. 

But  the  chain  of  gradually  decreasing  glands  from  the  neck 
or  inguinal  glands  to  the  bronchial  glands,  and  also  the  frequently 
radiating  dispersal  of  the  tuberculous  processes,  exhibits  itself  in 
cases  where  an  after-infection  is  almost  impossible. 

Acain,  if  we  infect  in  a  hind  legf,  w'e  observe  a  caseation  of 
the  inguinal  and  peritoneal  glands,  tuberculosis  of  the  li\-er  and 
spleen,  and  on  killing  the  animal  later  we  hnd  pulmonary 
tuberculosis  and  moderate  enlargement  of  the  bronchial  glands. 
\\''hv  does  the  infection  of  the  lung  appear  so  late  if  the  toxin 
has  dispersed  bv  wa\'  of  the  blood-vessels,  as  the  capillaries  of 
the  lungs  are  the  first  filter  (and  the  lung  is  alleged  to  have  a 
special  predisposition  for  absorption)  ?  On  the  other  hand,  if  we 
infect  in  the  area  of  the  neck  glands,  how  is  it  that  caseation  of 
the  neck  glands  appears  sooner,  with  tuberculosis  of  the  lungs 
and  bronchial  glands;  and  infection  of  the  liver  and  spleen  only 
later  ? 

It  will  be  difficult  to  explain  this  phenomenon  without 
acknowledging  the  possibility  of  infection  from  near-lying 
systems  of  lymph  glands,  even  if  they  are  analomicallv  separated. 
It  remains  an  open  question  whether  \ery  fine  capillaries  and 
anastomosing  channels  exist  which  have  hitherto  escaped  our 
researches  (see  also  Bartel  and  Neumann),  or  whether  the 
infectif)n  in  many  cases  is  not  conveved  by  contiguity  (Most). 
Concerning  retrograde  infection,  we  have  a  series  of  reliable 
observations  by  Tendeloo.  vSappey  and  Kiittner  have  proved, 
on  fresh  dead  bodies  of  children,  a  connection  of  the  Ivmph 
passages  between  mediastinal  and  parapancreatic  Ivmph  glands 
passing  through  the  diaphragm,  and  Bartel  calls  to  mind  with 
me  the  lymphogenous  metastasis  of  tumours,  which  also  do  not 
keep  strictly  to  the  lymphatic  system  (see  p.  222,  Retrograde 
Dispersal). 


GKNKSIS     OF    SCKOl'LLOSJS  I  27 

v.— THE  PART  PLAYED  BY    IMF:  LYMPH 
GLANDS. 

In  scrofulosis  llie  lyni[)li  glands  play  (jiiit(;  a  dilTfrf^nl  part 
from  vvlial  was  lornicrly  siip|)()sc(l.  On  account  of  tin;  frf;(jufnl 
and  obslinale  affections  of  glands  iIm-  (orKlnsion  was  comf;  l<j, 
posL  lioc,  tiKit  patients  with  a  icndency  in  scrofulosis  are  of 
specially  weak  constitution  and  not  capable  of  coping  witli 
])atliogenic  germs  or  irritants,  wliilsi  ilie  lynipli  glands  of  healthy 
persons  can  cope  with  Uiem. 

According  to  our  opinion,  il  is  iheji-  exposed  i)osition  near 
the  peri[)her\',  the  outer  boundary  of  liic  body,  I  heir  (  jiaraclers 
£is  the  point  of  union  of  the  lymph  passages  leading  to  the  inner 
j3arts  of  the  body,  which  stamps  them  as  a  sort  (jf  second  line 
of  defence,  an  inner  fortress,  so  di\erting  the  attack  of  the  patlnj- 
genic  germs  to  themselves,  and  thus  concentrating  and  often 
sacrificing  their  existence  for  the  protection  of  the  organism.  It 
does  not  depend  on  the  nature  and  constitution  of  the  glands  nor 
on  their  individual  and  different  power  of  resistance,  but  on  the 
greater  or  less  power  of  protection  of  the  front  rank  (as  to  which 
we  have  to  consider  the  skin  and  mucous  meml)ranesj,  whether 
they  form  the  more  or  less  frecjuent  field  of  battle. 

A  few  even  are  of  the  opinion  that  certain  groups  of  glands 
are  more  especially  disposed.  For  example,  Suchannek  declares 
that  the  tubercle  bacilli  conveyed  by  the  placenta,  scantilv  and 
irregularly  dispersed  over  the  whole  body,  only  thrive  after  birth 
in  certain  places  suitable  for  their  further  development;  for 
example,  the  bronchial  and  cervical  glands.  But  our  experimental 
and  clinical  experience  (see  pp.  79  and  85)  shows  the  contrarv, 
that  with  animals  the  affection  of  the  glands  exhibits  itself  in  the 
gland  nearest  to  the  place  of  infection  and  continues  from  there 
in  distinctly  defined  succession,  and  that  in  man,  wherever  a  tuber- 
culous focus  is  formed  the  affection  of  the  glands,  if  it  should 
declare  itself  and  be  noticeable,  always  declares  itself  according  to 
rule  in  the  nearest  region  and  not  in  an  irregular  wav  anvwhere. 

The  greater  frequency  of  infection  of  a  certain  group  of 
glands — for  example,  the  bronchial  glands — leads  to  the  conclu- 
sion that  this  area  of  absorption  is  more  exposed  to  opportunities 
of  infection. 

A  statement  to  the  contrary  would  make  it  our  dutv  to 
contradict  it,  basing  our  opposition  on  facts  confirmed  bv 
thousands  of  experiments  on  animals. 

If  one  accepts  the  mesenteric,  bronchial,  or  cervical  glands 
as  having  a  special  tendency  to  scrofulosis,  it  is  about  the  same 


I2S  SCROFLLOSIS 

as  it  we  were  lo  consi(-ler  ihe  inguinal  glanils  specially  disposed 
to  syphilis. 

Anatomical    Protective    Effect   of   the    Lymph   Glands.— The 

designation  lA  the  1\  niph  glands  as  i3roiecii\e  organs  and  tillers 
is  juslilied  bv  their  anatomical  construction.  The  cor]niscul  ir 
elements  of  everv  sort,  such  as  cinnabar,  and  carbon,  and  bacteria, 
brought  tt)  them  bv  the  afferent  vessels  are  detained  first  in  the 
lymph  sinuses,  which  surround  the  follicles  of  ilu'  cortex,  through 
the  dividing  wall  of  the  dense  reticulum,  which  oi-)poses  itself 
as  a  system  of  defence,  which  has  now  beccMiie  broader  and  so 
frees  the  hmpli  hi're  cuul  in  its  fiu'iher  course  from  loreign  bodies.^ 

Naturally  this  protective  power  has  its  limits,  if  all  at  once 
enormous  quantities  of  germs  penetrate  (too  mg.  pure  culture,  as 
is  often  emploxed,  contains,  according  to  L.  RalDinowitsch, 
about  40,000  tuliercle  bacilli),  or  when  they  are  injected  under 
great  pressure,  the  filler  becomes  insufficient  and  is  broken 
thrcTugh  ;  in  the  case  of  mixetl  infection  and  trauma  the  filtering 
power  appears  to  fail  more  easily  (see  also  Noetzel). 

The  filtering  power  also  depends  very  much  on  the  nature 
of  the  foreign  both,  and  in  the  case  of  germs  on  their  \iiiilence. 
Thus  granules  of  Indian  ink  are  on  the  whole  more  easily  let 
thrt)ugh  than  bacteria  ;  inoffensive  bacteria,  such  as  the  human 
bacillus  in  the  rabl^it,  which  do  not  irritate  the  tissues,  pass 
through  more  easily  th<'in  the  bovine  bacillus;  according  to  this 
we  may  take  it  that,  (Mi  the  other  hand,  bovine  bacilli  in  sus- 
ceptible persons  pass  more  easily  through  the  glands  than  human 
bacilli,  a  consideration  which  perhaps  may  explain  many  contra- 
dictory results.  These  consequences  will  be  again  annulled,  as 
the  non-virulent  bacilli  will  not  produce  any  virulent  effect  in  the 
place  where  they  are  further  deposited.  But,  against  this,  they 
form  one  of  the  most  frequent  causes  of  the  so-called  latent  foci, 
for  the  deposition  of  tubercle  bacilli,  which  are  virulent  to  the 
guinea-pig,  but  in  the  human  body  produce  few  or  no  changes  of 
tissue — Bartel's  lymphoid  tubercle. 

Toxic  Protective  Influence  of  the  Lymph  Glands. — The  lymph 
glands  form  (with  the  exception  of  the  afferent  and  efferent  blood- 
vessels which  nourish  them),  on  account  of  their  capsules,  organs 
which  are  entirely  enclosed.  The  toxins  produced  bv  the  bacteria 
— I  refer  here  to  the  tubercle  bacilli  which  e?ccite  the  periphery 
of  the  tuberculous  foci  to  reaction  and  inflammatory  encapsulation 
and  so  form  the  real  foundation  of  natural  healing — as  explained 
in  my  book  on  "Tuberculosis,"  second  edition,  p.  682 — will 
therefore   not   diffuse   themselves  so  easily   into  the   further  sur- 

'  For  the  construction  of   lymph  glands,  sec  also  Bartel  and  Stein. 


l;knI';.si.s   oI'    sckom  ),f>sis  ikj 

rounclings  bill  will  !)<■  id.-iiiH'd  in  (jiu'  pl.-ur.  (  )n  iIk-  one  li.-iiid, 
on  a(x;<)iiiU  ol  llicir  lii;;li  (lc,L;rci-  <il  (  oim  ciii  in  lion  llic  growili  ol  tiic 
bacilli  is  liintlcicd,  ;iii(l  on  ilic  oilier  h.-md  iliey  cause  an  inw-nsiv 
n^aclion  of  llic  lissiic,  ivnd,  owin^'  lo  .-i  <  lifinical  substance  conlainr-d 
in  dicin  wliicli  induces  coaj^iiial  ion,  lend  lo  stasis  and  tiironibfjsis 
of  (he  blood  .'Hid  Unipli  xcsscls  in  I  In-  ;iic,-i  ol  die  I  o(  us.  'Ilif  inicr- 
ruption  of  llic  hnipli  ;iiid  blood  niricnls  icsnliin^-  from  llic  latter 
is  s|)eci<-ill\'  iinporlant,  ])ecause  l;y  me.'ms  of  iliis  ;i  fnrtii'-r  dispersal 
of  llic  ^ciins  is  prevented. 

Il  c.'innoi  .'ii  prcscnl  be  jud^t^cd  how  l;ii-  die  presence  ol  numer- 
ous hniph  corpuscles  in  liie  Kinpli  glands,  in  Metchnikorf  s 
sense,  or  in  die  sense  of  l)ein<4  an  aniiloxin,  ike,  lias  any  influence. 

At  a  certain  stage  we  find  with  the  tubercle  an  immigration 
of  leucocytes,  evidently  as  the  expression  of  a  certain  tendency 
to  heal.  Leuc()C}tes  are  already  present  in  the  lymph  glands,  and 
thus  a  later  stage  of  Ihe  tubercle  is  anticipated  at  a  time  when  the 
tubercle  bacillus  has  not  yet  arrived  in  the  neighbouring  tissues. 

Manfredi  and  his  pupils  have  made  extensive  researches,  and 
proved  an  influence  which  weakens  the  virulence. 

Bartel  and  Neumann,  on  the  basis  of  their  researches,  ascribe 
a  far-reaching  part  lo  the  leucocytes  in  making  the  tubercle  bacilli 
innocuous  (see  also  Livierato). 

The  lymph  gland  cannot  play  the  part  of  a  protector  in  all 
diseases  with  the  same  success  as  with  the  tubercle  bacillus.  In 
those  diseases  in  which  the  causative  agent  grows  in  the  blood 
itself — for  example,  anthrax  bacillus — they  do  little  or  nothing. 
The  glands  cannot  then  prevent  the  bacillus  from  forcing  a  wav 
through  ;  at  the  most  they  can  but  dela^-  it,  and  in  a  short  time 
we  find  all  the  glands  of  the  body  swollen.  Much  depends  upon 
the  power  of  motion  in  the  bacteria,  on  the  chemical  nature  of 
their  poison,  on  the  rapidity  of  their  proliferation,  and  manv  other 
circumstances,  in  judging  how  far  they  can  fulfil  their  task.  It  is 
a  mistake  to  go  too  far  in  exemplifving  one  result  of  infection  bv 
another,  as  if  every  species  of  bacteria  had  not  its  own  specific 
action,  which  needs  to  be  considered  in  all  its  consequences  and 
irritation  phenomena. 

As  we  no  longer  consider,  as  formerlv,  an  affection  of  the 
glands  to  be  a  predisposition  only  of  the  affected  gland  area,  an 
expression  of  dyscrasia,  and  as  we  must  ahvavs  keep  our  eve  on 
the  absorption  area,  I  think  an  anatomical  resume  of  the  glands 
coming  principally  into  consideration  is  advisable.  I  draw  mv 
material  chiefly  from  the  works  of  Hvrtl.  Hoffmann,  and 
especially  Henle.  The  knowledge  of  the  area  of  the  source  and 
distribution  is  important  for  prophvlactic  and  therapeutic  pur- 
poses, because  it  is  our  duty  to  close  the  paths  of  entrv. 

Q 


I30 


SC"K(^FL  I.OSIS 


AlTcreul  vessels  from 


ElTerent  vessels  lo 


Facial,  anterior  superHcial 
auricular   glands. 

Sifiiation. — On  and  in  the 
parotid,  in  front  of  the  ex- 
ternal auditory  meatus 

Deep  facial  glands  (bucci- 
nator) 

Siiiia/ioii. — Hinder  part  of 
the  buccinator.  Lateral 
wall  of  the  pharynx 


Occipiial  glands 
Siluatioii.  -  Origin 
trapezius. 


of     the 


Mastoid  glands  (sub-auricu- 
lar, post-auricular) 

Situatio)!. — Insertion  of  the 
sterno-mastoid  behind  the 
ear 

Sub-maxillaty  glands 

Si//ta//o/i.  —  Suli  -  maxillary 
glands  and  lietween  them 
and  the  inner  surface  of 
the  lower  jaw 


Superficial  cervical  glands. 
Superficial  jugular. 

Situation.  —  Upper  side  of 
the  neck  in  front  of  and 
over  the  sterno-mastoid 
along  the  external  jugular 
vein 

Superior  deep  cervical  glands 
(superficial  jugular). 

Situation. — At  the  division 
of  the  carotid,  along  the 
internal  jugular  vein  to 
the  base  of  the  skull 


Infeiior  deep  cervical  glands 
(inferior  jugular,  supra- 
clavicular). 

Situation. — In  the  supra- 
clavicular fossa  to  both 
sides  of  the  trunk  of  the 
great  vessels 


Temporal  region 


To    the     sub-maxillaiy    and 
superficial  cervical  glands. 


Temporal,      spheno  -  maxil-    Supeificial  and  deep  cervical 
lary  group,  eye  and   no=e        glands, 
cavity,  upper  jaw,  palate, 
pharynx,    to    part    of   the 
l)rain  (Arnold)  i 

Parietal  and  occipital  region      Superficial  cervical  glands. 


Superficial  and  deep  cervical 
glands. 


Superficial  and  deep  cervical 
glands. 


Back  of  the  ear 


Face,  lips,  floor  of  the 
mouth,  salivary  glands, 
forehead,  eyelids,  bridge 
of  the  nose,  aire  nasi,  upper 
lip,  gums  of  the  lower 
teeih,  chin,  tongue,  effe- 
rent vessels  of  the  super- 
ficial facial  glands 


External  ear,  skin  of  the  Deep  inferior  cervical  glands, 
nape  of  the  neck,  efferent  i 
vessels  of  the  occipital 
glands,  sub-auricular  to 
part  of  the  superficial, 
facial,  and  sub-maxillary 
glands 


Efferent  vessels  of  the  deep 
facial  glands,  lingual,  and 
a  part  of  the  sublingual 
gland,  the  cranial  cavity 
to  a  part  of  the  tongue, 
larynx,  thyroid  gland , 
lower  pharynx,  deep  neck 
muscles 

All  the  lymph  vessels  of  the 
head  and  neck,  efferent 
vessels  of  the  superficial 
cervical  glands,  and  the 
upper  deep  cervical  glands 


Deep  inferior  cervical  glands. 


Unite  with  the  jugular  lym- 
phatic trunk  on  the  left, 
opens  into  the  thoracic 
duct  on  the  right  into  the 
common  lymphatic  duct, 
or  the  sub-clavian  vein,  or 
the  internal  jugular  vein. 
Branches  leading  to  and 
from  the  axillary  and  thor- 
acic glands.  The  inferior 
deep  cervical  glands  are 
often  united  in  a  continu- 
ous chain  through  certain 
glands  met  with  in  the 
middle  of  the  neck. 


GiiNKSis   op-   scKOFi/r/^srs 


r-?! 


Nfinie 


Anterior  mediastinal  glands. 

Siltiadon. — In  front  of  the 
pericardium,  close  al)ovc 
tlie  dinphragm,  in  front 
of  the  aorta  and  the  left 
innominate  vein 

Posterior  mediastinal  glands. 
Situation. — Along    the   thor- 
acic aorta 


bronchial  ([ndmonary)  glands. 

Situation.  —Smaller  (pulmon- 
ary glands).  In  ihe  hilum 
of  the  lung  to  the  lironchial 
branches,  larger  vessels  to 
the  under  surface  of  the 
trachea  (tracheal  glands) 
their  divisions  and  the 
bronchi 

Lumbar  glands. 

Situation. — Three  rows  on 
the  hinder  surface  of  the 
abdominal  aorta,  the 
medium  -  sized  at  the  bi- 
furcation and  the  trunk  of 
the  aorta,  the  lateral  group 
between  the  transverse 
processes  and  the  lumbar 
vertebrce 


Afferent  vcsscrl',  fi< 


Mesenteric  glands. 
Situation.  —  Between       the 
folds   of   the  mesentery 


Coeliac  glands. 

Situation. — In  front  of  the 
aorta  over  the  origin  of 
the  superficial  mesenteric 
artery,  between  and  be- 
hind the  folds  of  the  trans- 
verse meso-colon  and  the 
gastro-hepatic  ligament 

Anti-brachial  glands 

Situation. — Exceptionally  to 
the  forearm  in  the  course 
of  the  lymph  vessels  accom- 
panying the  radial  and 
ulnar   arteries. 


Efferent  vessels  of  the  ster- 
nal glands.  Greater  part 
of  tlie  liver,  the  front  half 
of  the  diaphragm,  the 
thymus,  pericardium,  and 
heart 

(J'isophagus,  hinder  septum 
of  tlie  ]:)eticardium  and 
diaphrngm,  to  part  of  the 
right  border  of  the  liver 

Especially  the  lungs,  trachea, 
the  posterior  cardiac  wall, 
the  efferent  vessels  of 
the  posterior  mediastinal 
glands.  (Esophagus,  hin- 
der surface  of  the  pericar- 
dium and  hinder  part  of 
the  diaphragm,  right  bor- 
der of  the  liver 

Efferent  vessels  of  the  entire 
group  of  pelvic  glands 
(iliac,  hypogastric  and 
sacral),  indirectly  the  in- 
guinal glands,  the  deep 
lymph  vessels  of  the  pos- 
teriorabdominal  wall,  back 
muscles  of  the  correspon- 
ding part  of  the  vertebral 
column  and  the  lumbar 
cavity  and  the  under  sur- 
face of  the  vertebral  part 
of  the  diaphragm,  the 
lymphatics  of  the  sigmoid 
flexure,  the  •  abdominal 
viscfera  and  a  part  of  the 
pelvic  viscera 

The  lymph  vessels  of  the 
small  intestines,  chylifer- 
ous  or  lacteal  vessels  and 
those  of  the  colon  to  the 
sigmoid  flexure. 

A  part  of  the  liver,  the 
stomach,  and  the  upper 
half  of  the  duodenum,  the 
pancreas  and  the  spleen 


ICfTcrent  veweld  to 


The  right  nnd  left  common 

lymf)hatic  trunk. 


Direct  thoracic  duct  or  bron- 
chial glands. 


On  tlie  left  with  or  without 
efferent  vessels  of  the 
sternal  and  mediastinal 
glands  to  the  thoracic 
duct  ;  on  the  right  the 
broncho-mediastinal  trunk 
which  receives  the  efferent 
vessels  of  the  remaining 
right  thoracic  glands. 

Unite  on  each  side  tcT  the 
lumbar  trunk  root  of  the 
thoracic  duct. 


Unite  in  the  intestinal  trunk, 
a  root  of  the  thoracic  duct. 


Take  part  in  the  intestinal 
lymphatic  trunk,  also  con- 
nected with  the  upper 
lumbar  glands. 


1.^2 


SCROI-l  I.OSIS 


Name 

AlTen-m  vc-vsels  from 

ElTc-ient  vessels  to 

Superficial    and    deep    ulnar 

The  superficial  ulnar  receive 

Axillary  glands. 

glands 

in     part     the     lymphatic 

Si/ua/ion. -^The  median  epi- 

vessels  of  the  hand,  while 

condyle    over    .the    elbow 

the  lymphatic   vessels   on 

joint 

the  radial  side  mostly  go 
direct  to  the  axilla. 

Axillary  glands 

Upper  extremity,  upper  part 

Axillary  lymphatic  tiunk  or 

Si/i/ti/io/t. — The  vessels  and 

of  the  .interior  and  poste- 

chief   ves<el,    or    a    large 

nerves   of   the    axilla   and 

rior  body  wall,  navcl  and 

cervical  vein. 

the    inner    border  of    the 

lumbar  region,  the  mamma 

pectoralis  major 

Unite!  with  ilie  deep 

inferior  cervical  inland. 

Popliteal  glands 

Superficial  vessel  of  the  leg 

Sitiia/ioii.  —  The     popliteal 

from  the  lateral  border  of 

vein 

the  foot 

Superficial  inguinal  glands. 

Abdominal  wall,  nattrs^  per- 

Deep inguinal  glands. 

Si  dial  ion.  —  From    Poupart's 

ineum,  anus,  and  external 

ligament  to  the  fossa  ovalis, 

genitals,     external      lym- 

thencesurroundingthegreat 

phatic  vessels  of  the  lower 

saphena  vein 

extremities 

Deep  inguinal  glands. 

The  deep  lymphatic  vessels 

Iliac  glands. 

Situation.  —  To    the    lower 

of  the  anterior  side  of  the 

limb  vessels  as  far  as  the 

thigh    and     the     efferent 

septum     crurale      by     the 

vessels   of   the  superficial 

crural    ring 

inguinal  glands,  epigastric 
and  circumflex  iliac  vessels 

Numerous  anastomoses  wiih 

the  superficial  branches. 

VI.— MODE  OF  INFECTION   IN  MAN. 

Experimenlal  proof  exists  as  lo  llie  possibility  of  an  infection 
of  the  skin  and  mucous  membranes  and  the  glands  connected  with 
them  b\-  direct  contact  with  the  bacteria,  which  we  shall  now  take 
into  consideration.  Clinical  observations  confirm,  as  far  as  the 
process  can  be  observed  in  man,  that  similar  conditions  pro- 
duce similar  effects.  And  now  we  must  show  in  everydav  life, 
especially  in  the  child,  the  opportunity  of  a  direct  contact  with 
the  various  bacteria  corresponding  to  these  experiments,  in  order 
to  establish  full  analog}'  with  experiments  on  animals  and  arrive 
at  logical  and  correct  conclusions  from  our  findings. 

In  another  place  (p.  130)  we  shall  siiow  that  Ixuteria  only 
enter  the  body  from  the  outside,  and  that  in  the  case  of  tubercle 
bacilli  a  uterine  transmission  cannot  be  taken  into  practical 
consideration. 


(1)  RELATIVE    FREQUENCY    OF   VARIOUS    LOCALIZATIONS. 

Accurate    and    reliable    examples    are    wanting    as    to    the 
frequencv    of    scrofulous    diseases  of    \ari()us    organs    and    gland 


(ii;NI':.SI.S     ()!<■    SCKOM.I.OSIS 


'33 


sLruclures.  Surgeons  do  iioi  <»ficii  come  in  conlact  with  ilie 
endless  number  of  broiu  iii.il  ;iihI  iiK'Sc^nlerin  scrofulous  diseases, 
and  consequenlly  ignnic  ihcm.  Ag.-iin,  sIimI'-his  miss  a  large 
number  of  advanced  exUnnal  fc^rms  of  scrofula  because  iliey 
re(|uire  operative  interfenMice.  Many  cases  of  scrofulous  eye  and 
ear  diseases  go  lo  a  si)ccialisl;  llx-  morbid  anaWimisl  sees  in  llif 
main  only  the  most  severe  tuberculous  forms,  while  the  numerous 
pvogenous  cases  vvhicli  have  mostly  healed  escape  his  notice. 

1'he  following  examples  afford  us  an  approximate  sur\ey. 
In  the  Empress  Elizabeth  Children's  Hospital  ai  Bad  Hall  there 
were  under  treatment  during  forty  years,  according  to  Rabl  :  — 

Cases. 

Affections  of  bones   and    j<jints  ...  ...  ...  

Affections  of  glands 
Afl'cctions  of  the  eyes    ... 
Affections  of  skin  and  cellular  tissues 
Affections  of  mucous   membranes 
Affections  of  ears 


According  to  Monti,  in  Salzbach  and  S.  Pelagio  :■ 

Scrofulous   disorders   of    nutrition 
Affections  of  the  eyes 

Affections  of  the  ears      ...         ...         ...         ...         ...         

Affections  of  the  nose 

Affections  of  the  skin 

Simple  hypertrophic  swellings  of  lymph  glands   ... 

Periostitis     ... 

Tuberculous    lymph    glands 

Caries 

Caries,  of    the    spine 

Coxitis 

Fungous  joint   --lisease 


2,147 
io5o 
',787 
1,1 13 
230 
145 


Cases 

308 

173 

5 

48 

102 

362 

33 

2Q1 

717 

165 
167 

18.' 


Even  in  the  diseases  of  the  glands  these  examples  do  not 
suffice  for  statistical  purposes. 

According  to  Volkmann,  of  external  glands,  the  neck  glands 
are  most  often  affected,  then  the  ulnar,  more  rarely  the  axillary, 
and  very  seldom  the  popliteal  and  inguinal  glands. 

The  following  give  the  results  as  to  frequency  :  — 


Neck  and  occipital  glands 
Axillary   glands 
Inguinal       ,, 

Ulnar  ,,  

Popliteal 

In  front  of  and  behind  ear 


According  to 
Balmann 

Wohlgemuih 
(430  cases) 

8ro  per  cent.     . 

6'o         ,, 

■  ■     93'00 
.        2-78 

per  cent 

7'o         „ 

093 

5"o         ,, 

0'23 

07 

0^3 

...        2'Q 

134  SC  ROI-ILOSIS 

In  Lcvin(,>,  among  288  tuberculous  gland  alTeciions,  there 
were  treated  :  — 

Cases 

Lateral    cervical    glands            ...         ...         ...         ...         ...         ...         ...  132 

Submaxillary    and   cervical    glands    ...         ...         ...  114 

Axillary,   lateral  cervical,  and  submaxillary  glands       ...         ...         ...  10 

Parotid    glands       ...         ...         ...         ...         ...         ...         ...         ...         ...  8 

Popliteal       1 

Multiple        23 

Lcbcri,  among  158  cases  of  scrofula  of  ilic  c.xu-rnal  glands, 
found  the  neck  glands  alone  affected  108  limes,  and  in  conjunciion 
widi  clavicular  axillary  and  sternal  glands  thirty  times. 

If  one  excludes  the  bronchial  and  mesenteric  glands,  one  can 
justly  term  the  cer\ical  giand.s  "  the  true  representatives  of 
scrofula  "  (w  liergmann).  But  according  to  the  exjDerience  of 
morbid  anatomy,  which  affords  us  relati\-ely  accurate  information 
respecting  the  bronchial  and  mesenteric  glands,  though  ihe\'  often 
escape  the  most  careful  clinical  observation,  yet  liiey  surpass  all 
other  series  of  glands  in  fre(|uencv  in  tul^erculous  scrofulosis. 
For  instance,  Miiller  (Cornet,  "  Die  Tuberctilose,"  second  edition, 
p.  361)  in  500  autopsies  under  15  years  of  age  found  tuberculosis 
of  the  lymph  glands  126  times,  in  which  tuberculosis  of  the 
bronchial  glands  occurred  103  times. 

How  far  they  occupy  a  more  or  less  prominent  place  in  the 
pyogenous  form  cannot  be  estimated;  such  swellings,  although 
chronic,  yet  after  a  time  again  retrograde,  and  cannoi  be  easily 
demonstrated  at  the  autopsy,  and  in  most  cases  are  onl\  brought 
to  light  if  they  have  caused  fatal  complications. 

Biederi  found  in  i  ,346  aiUopsies  of  tuberculotis  children,  with 
or  without  tuberculosis  at  the  seat  of  origin  of  the  disease  (i.e.,  the 
lungs  and  intestines),  that  the  bronchial  glands  were  affected  in 
78  per  cent.,  and  the  mesenteric  glands  in  10  per  cent,  of  the  cases. 
Meeker  in  96  per  cent,  of  the  cases  of  tul)erculosis  in  children 
which  ended  fatally  found  the  Ivmph  glands  affected  in  92  per 
cent.,  and  the  bronchial  glands  in  50  per  cent.  C'arr  in  120 
autopsies  of  tuberculous  children  found  the  l^ronchial  glands 
implicated  in  80  per  cent.,  and  the  mesenteric  glands  in  54  per 
cent.  Frobelius,  in  the  foundling  hospital  at  St.  Petersburg, 
among  416  autopsies  on  cases  of  tuberculosis,  found  the  bronchial 
glands  tul^erculous  in  99*2  per  cent.,  and  the  mesenteric  glands 
in  i6'i  per  cent.  Briining  in  400  autopsies  on  children  found 
tuberculous  changes  of  the  organs  44  times,  of  which  77  per 
cent,  were  in  the  bronchial  glands,  and  57  per  cent,  in  the 
mesenteric    glands.     Stirniniann     in    591     autopsies    on    children 


GENESIS    OJ-     SCKOFCLOSIS  1 35 

under  one  year  loiind  42  casfs  I  iilx  r(  nloiis,  hni  oiil\  dh'-  <  liild 
in  whom  (he  orj^ans  of  rcspiial  ion   \\,fic  nol  rdlcflcd. 

Mendclsolin  louiid  lliai  2<)2  (or  2327  |)<-r  (<-iii.;  wrvc  iuImt- 
CLilous  oiil  of  1,-^55  aiilo|).sir,s  on  (  liiKlrcn  ;  primary  isolalffl 
tuberculosis  ot  llic  orj^ans  of  i-cspiraiion  onl\'  (ini  hiding''  llie 
bronchial  ^dands)  in  29  (1051  per  rcni.j;  primary  tuberculosis  of 
the  organs  of  respiration,  wiMi  disseminaicd  loci  throughout  th':; 
body,  in  <J4  (34'^>^>  P<-'i"  <"<"'ii.) ;  primary  (ulx-r*  niosis  of  dif  intestines 
only  in  18  (6'52  per  cent.);  primary  lulx-ii  ulosis  of  \\\f  intestines, 
with  disseniinated  foci  throughoui  ihc  l)od\-,  in  7  C2'54  per 
cent.). 

Albrecht  had  similar  results.  According  to  him,  among  3,213 
autopsies  on  children,  of  wliom  1,060  were  tubercuUjus,  the 
tracheo-bron(-hial  glands  were  prominently  affected.  Feldmann 
also,  among  752  autopsies  on  children,  of  whom  19  per  cent,  were 
tuberculous,  found  tuberculosis  of  the  bronchial  glands  and  lungs 
most  frequentl\-.  Schlossmann,  who  regards  infection  from  f|uite 
a  different  standpoint,  admits  that  the  l)ronchial  glands  are  withrjut 
exception  affected  in  tuberculosis.  Meubner  sa\'S  phthisis  in 
children  has  its  seat  in  the  bronchial  glands.  Thus  we  see  that 
the  bronchial  glands  decidedly  hold  the  llrst  place  in  fref|uenc\-  in 
tuberculosis. 

Watson  Cheyne  computes  the  frequency  of  diseases  of  bone 
on  the  basis  of  the  reports  of  various  authors  (Billrodi-AIenzel, 
Jaffe,  Schmalfuss,  and  his  own  cases). 

Vertebral    column        ...  ...  ...  ...  ...  ...  ...  23'2  per  cent. 

Knee-joint          ...         ...  ...  ...  ...  ...  ...  ...  i6'5         ,, 

Hip-joint              ...          ...  ...  ...  ...  ...  ...  ...  i4'6         ,, 

Tarsus  and  anL^e-joint  ...  ...  ...  ...  ...  ...  i4'4         ., 

Elbow-joint        ...          ...  ...  ...  ...  ...  ...  ...  6'3 

Cranium    and    face      ...  ...  ..:  ...  ...  ...  ...  5' 5 

Breast-bone,   clavicle,   ribs  ...  ...  ...  ...  ...  ...  5'2 

Pelvis       ...          ...          ...  ...  ...  ...  ...  ...  ...  5'2 

Femur,   fibula,   tibia    ...  ...  ...  ...  ...  ...  ...  3' s 

Shoulder-joint    ...          ...  ...  ...  ...  ...  ...  ...  I's 

Shoulder-blade,  ulna,   radius  ...  ...  ...  ...  ...  To 

According"  to  Sprengel,  the  frequency  of  bone  and  joint 
disease  is  as  follows  :  Spondylitis,  coxitis,  tuberculous  ostitis  of 
the  small  bones  of  the  hand  and  of  the  foot,  inflammation  of 
knee-joint,  tuberculous  ostitis  of  the  long  bones,  tuberculosis  of 
the  ankle-joint,  tarsus,  elliow,  shoulder  and  wrist. 

According  to  Jaffe  the  vertebral  column  was  affected  in  26 
per  cent.,  the  tarsus  in  21  per  cent.,  the  hip-joint  in  13  per  cent., 
the  knee-joint  in  10  per  cent.,  the  hand  bones  in  g  per  cent.,  the 
elbow  in  4  per  cent. 


1  j;6  SCROI-ULOSIS 

(2).     THE  CAUSES  OF  DIFFERENT  LOCALIZATIONS. 

It  would  lead  us  luo  tar  lo  enter  iniu,  and  lo  discuss^  here  the 
occasions  in  which  infection  of  the  skin  and  mucous  membranes 
takes  place,  and  the  conditions  which  favour  and  retard  infections 
in  particular  parts  of  the  body. 

A  detailed  account  respecting  the  tubercle  bacilli  is  to  be 
found  in  the  second  edition  of  my  "  Tuberculosis."  Almost  the 
same  conditions  apply  respecting  the  pus  bacteria,  with  the  differ- 
ence that  the  latter  increase  more  quickly  and  locate  themselves 
more  easily.     We  will  liniii  ourselves  here  to  a  short  sketch. 

As  the  skin  on  account  of  its  first  tissue  is  capable  of  retaining 
the  whole  or  part  of  any  germ  which  penetrates  it,  we  can,  in  the 
case  of  the  skin,  establish  much  more  easily  by  the  local  elTects 
the  frequency  with  which  certain  places  become  the  point  of  entry 
of  the  infecting  germs  than  in  the  case  of  mucous  membranes  in 
which  the  position  of  the  diseased  glands  must  give  the  clue  to 
the  place  of  infection.  When  changes  are  met  with  in  the  glands 
we  can,  with  greater  probability,  take  for  granted  a  bacterial 
invasion  of  mucous  membrane. 

The  diseased  glands,  and  the  knowledge  of  their  seat  of 
election,  affords  us  the  best  guide  as  to  the  most  frequent  point 
of  entry  of  infection,  according  to  the  law  of  localization  (see 
pp.  63  and  88). 

According  to  Most,  who  has  thoroughly  investigated  the 
matter,  in  two-thirds  of  the  cases  of  scrofula  and  tuberculosis 
the  deep  cervical  glands  are  most  often  affected,  and  especially  the 
glands  lying  to  the  middle  and  side  of  the  jugular  vein,  and  the 
Ivmphatic  glands  at  the  angle  of  the  common  facial  and  internal 
jugular  veins.  The  result  of  experimental  infection  of  the  palatine 
and  pharyngeal  tonsils  tallies  with  this. 

Most  lays  special  stress  upon  the  regularly  descending  and 
rarelv  disseminating  course  of  the  glandular  swelling,  which 
diminishes  as  they  extend  downwards.  The  glandular  swelling 
ceases  about  halfway  up  the  neck  at  about  the  crossing  of  the 
omohyoid  and  the  jugular  vein  (where  the  middle  of  the  deep 
cervicals  divide  and  become  the  cervical  trunk).  I'he  supra- 
clavicular, which  lie  deeper  down,  and  which  receive  the  lymph 
from  the  trachea,  oesophagus  and  the  lateral  deep  cervical  glands, 
are  very  seldom  affected,  and  only  in  \ery  advanced  cases. 

Tn  a  small  number,  in  about  one-third,  (he  glands  rii  the  hDrder 
of  the  jaw  are  affected,  the  submental,  submaxillary,  ant!  suhauri- 
cular  alone,  or  with  their  effluents  and  the  deep  cervical  glands. 
Thev  point  to  a  disease  of  the  front  half  of  the  face,  scrofulous 
eczema,  affections  of  the  mouth,  teeth,  nose,  eyes  and  ears. 


GliNIiSIS    Ol'     SCROI'LI.OSI.S  137 

SKIN. 

Ill  (lie  lrc(|ii('n(;)-  ol  |))()(^('ni(;  .s(  ml  iilous  diseases  a  striking 
dislinclion  is  incl  wiili  in  iIk-  \arioiis  regions  of  llie  skin.  Most 
oflen  llic  skin  ol'  ilic  Km  (;  iind  scalp  forms  llie  seat  (jf  scrofulous 
diseases,  niiicii  less  ofu-n  Uie  hands,  and  very  seldom  the  feet  and 
trunk.  In  1  lO  cases  ol  scrofnloiis  skin  diseases  observe(J  by 
Lebert,  91  vvcrci  situated  on  llic  head,  and  of  these  31  were  on  ihe 
scalp,  in  the  tuberculous  form  alone,  Neukirch  f(jund  in  55 
cases  of  lupus  44  on  the  lace  (in(  hiding  ihe  forehead  and  nr>se), 
two  on  the  neck,  live  on  the  hand  and  arm,  one  eacli  on  the  leg 
and  fool.  According  tf)  Cramm's  list  of  ( ases,  573  instances  of 
lupus  occur  on  non-iiairv  parts,  69  on  hair\-  parts.  In  IJahn's 
424  cases  of  lupus,  onl}-  105  (occurred  on  the  extremities,  and 
singly  only  in  eight  cases,  while  44  times  in  the  105  cases  tfie 
face  \\as  first  affected. 

The  skin  of  the  face  in  its  cnitward  ap|)earance  is  mucii  softer, 
freer  from  wrinkles,  and  smoother  than  that  of  the  hands,  for 
instance,  which,  by  use,  often  become  quite  indurated.  The  fact 
that  the  head  and  face  are  often  uncovered  and  are  thus  more 
exposed  to  dirt  and  infection  is  of  more  importance.  Added  to 
this,  children,  especially  under  one  year,  rummage  on  the  floor 
with  their  little  hands,  seize  matters  of  a  doubtful  nature,  and  then 
in  happy  ignorance  smear  their  dirty  hands  over  their  head  and 
face  or  in  their  ears,  or  are  "  made  clean  "  by  their  relations  with 
dirty  cloths  or  pocket-handlverchiefs.  Thus  a  little  girl  got  lupus 
of  the  nose  from  constantly  using  the  soiled  handkerchief  of  her 
tuberculous  sister  (Leloir,  Baginsky).  In  another  case  chronic 
eczema  in  a  child  of  a  tuberculous  mother  was  connected  with 
crusts  of  bread  sucked  by  the  mother ;  from,  this  act  lupus 
developed. 

The  researches  of  Preisich  and  Schiitz  show  us  how  the  virus 
of  tubercuU^us  parents  and  relatives  is  conveved.  In  a  polvclinic 
they  found  tubercle  bacilli  in  the  dirt  under  the  finger-nails  in 
21  per  cent,  of  consumptive  children,  amongst  sixtv-six  cases, 
and  Baldwin,  in  twenty-eight  consumptives  whose  hands  were 
washed  without  warning,  found  bacilli  in  eleven  cases.  Graziani 
in  eight  consumptives  found  virulent  bacilli  in  four  cases.  The 
latter  found  bacilli  on  his  own  hand  after  the  exchange  of  a  heartv 
handshake  with  a  consumptive.  Ostermann,  however,  had  a 
negative  result  in  a  similar  case.  On  the  other  hand,  Ostermann 
examined  the  hands  of  forty-two  children  of  phthisical  families, 
and  demonstrated  tubercle  bacilli  in  the  water  in  which  four 
children  had  washed,  in  fourteen  adult  consumptives  onlv  in 
seven    cases,    and   similarlv  on   the   hands  of  a   nurse,    and  also 


138  SCROI-'LLOSIS 

eslablisliL'd  iluu  ihc  i^crni  was  easily  set  free  by  pulling  ilie  lingers 
in  the  mouth  ami  ni>sr,  for  instance. 

The  same  applies  io  pus  ct)C(i. 

The  scalp,  as  opposed  to  ilie  fai'e,  is  i^roiecied  by  ihe  hair, 
bui  iliai  is  oft.en  not  kept  clean,  as  the  frei|uent  nestnig  of  vermin 
shows. 

Special  opporiuniiies  of  infi'cnion  ofu-n  oct'iir  troni  slings  ol 
gnats  and  insects,  irritation  of  scborrluva,  acne  pustules,  which 
cause  scratching  with  infected  lingers,  little  scratches  with  sharp 
combs  and  hairjiins,  b\-  a  fall,  or  in  play. 

Of  other  parts,  it  is  usuall\-  the  thin  surlace  of  the  baik  ol  the 
hand  which  is  the  seat  t)f  infection,  especially  the  groove  of  the 
nails,  which  furnishes  a  lurking  jilace  h)r  the  l:)acleria. 

Compared  w  ith  each  other,  the  tuberculous  form  of  scrofulosis 
of  the  skin  is  less  frecpieni  than  the  pyogenic  form,  because  the 
tubercle  bacilli  are  less  widelv  distributed,  and  especially  because, 
bv  the  low  temperature  of  the  skin,  they  grow  more  slowly,  and 
thus  can  be  more  easily  eliminated  than  pus  cocci  and  other 
bacteria. 

MUCOUS  MEMBRANES. 

As  from  the  greater  permeabilitv  of  the  (-hild's  mucous  mem- 
branes, isolated  germs,  especialK"  tubercle  l:)acilli  (see  p.  29),  not 
infrequentlv  reach  as  far  as  the  glands,  it  is  often  only  from  the 
diseases  of  the  glands  that  we  can  judge  of  the  fre(|uency  with 
which  the  mucous  memljranes  form  the  point  of  entr}'  and  also  of 
the  more  exact  position  of  ihe  latter. 

Those  mucous  meml)ranes  which  are  the  points  of  entry  of 
air  and  food  which  are  so  frequently  infected,  that  is  to  say, 
tliose  which  come  most  into  contact  with  the  outer  world,  namely, 
the  mouth  and  nose,  b\'  far  surpass  in  the  fref|uencv  of  the 
disease  the  usual  outlets,  the  anus,  urethra,  and  in  certain  cases 
the  vagina.  These  differ  among  each  other  according  to  the 
degree  in  which  thev  are  exposed  to  infection,  and  according  to 
the  sufficiency  of  the  protection. 

In  the  case  of  the  nose,  the  germ-laden  ins]iired  air  forms 
the  source  of  infection  which,  as  has  been  explained  elsewhere, 
is  here  exposed  to  a  process  of  deposit  by  the  vibrisscC  and  the 
various  ridges  and  depressions,  the  side  current  formed  bv  these, 
and  the  sinuous  course  of  the  breath  current,  h^urtlicr  (ipport unities 
are  now  and  again  given  by  the  bad  liabit  of  picking  the  nose, 
caused  by  the  irritation  of  worms  in  the  intestine,  and  the  intro- 
duction of  foreign  bodies  b\-  clirtv  lingers,  wherebv  bacteria 
adhering  to  them  and  tubercle  bacilli  are  often  undoubtedlv  rubbed 
in.     If  w-e  may  take  the  seat  of  tuberculous  changes  in  the  nose 


(JENKSIS     OJ'     SCKOl'O.OSIS  139 

of  jululls  as  a  slardard,  iIk-  scphini  and  ;i iiicrior  narcs  may  be 
especiallv  considered  ;is  poinis  ol  '•niiy  lor  scroluh^sis  (sftf; 
vSymplonis,  p.   \<)^). 

In  (lie  case  of  liic  naso-pliarynx,  die  inlialalion  of  bacleria 
nuisl  be  lakcn  in(o  consideration  in  ilie  Tirsi  place  for  this  spol 
on  analoniical  grounds,  and,  a(  ( < ndinL,^  lo  Kayser's  dusl  experi- 
ments (p.  139),  jusl  diis  position  next  lo  the  nostrils  forms  (lie 
chief  depot  for  the  deposit  of  dust.  Resides  which,  the  lymphoid 
tissue  of  Luschka's  tonsil  and  die  ,surfa(es  full  of  rrypis  arc* 
especially  suitable  for  absorption  and   reieniii.n. 

From  (his  spot,  bv  couq'hin'^  and  oHiei-  toi(cd  actions,  by 
sneezing  or  retching,  germ-laden  secretions  are  driven  througli 
the  luislachian  tube  to  the  middle  ear,  the  bacteria  llourish  on  the 
mucous  membrane,  which  may  be  either  intact  or  weakened  after 
measles  or  scarlet  fever,  &c.,  produce  middle  ear  catarrh,  or  are 
carried  to  the  glands  by  the  clefts  of  Santorini  (Ferreri),  which 
are  broader  in  children.  For  instance,  in  five  cases  of  what  wa.s 
apparently  primary  tuberculosis  of  the  ear  in  infants,  Ilaike  has 
been  able  to  trace  the  path  of  infection  from  the  pharynx  to  the 
tympanum,  sometimes  through  tuberculous  deposit  in  the  palate, 
and  sometimes  through  affection  of  the  Eustachian  tube.  For 
infection  of  the  outer  ear,  which  often  is  the  seat  of  eruptions, 
dirty  lingers,  foreign  bodies,  ear  scoops,  play  an  important  part, 
and  now  and  again  earrings  of  tuberculous  persons,  as  in  cases 
related  by  v.  During,  Unna,  Leloir,  and  Schiele. 

In  the  mouth  the  sources  of  infection  are  principally  from 
food  which  is  derived  from  tuberculous  or  diseased  animals  or  is 
decomposed,  or  is  accidentally  contaminated  by  pathogenic  air- 
carried  organisms.  On  the  other  hand,  the  bad  habit  of  children 
of  putting  dirtv  fingers  (see  Preisich  and  Schiitz,  p.  137)  or  odier 
things  into  the  mouth  is  the  cause  of  infection.  Tubercle  bacilli 
and  other  germs  can  easily  enter  the  open  mouth  with  the  respired 
air;  bacilli  mav  be  conveved  by  kissing  tuberculous  persons,  for 
although  the  saliva  is  generally  free  from  l^acilli,  particles  of 
sputum  mav  be  hanging  on  the  lips  or  moustache. 

Whether  the  bacteria  can  cause  infection  at  all,  and  in  what 
part  of  the  digestive  tract  in  the  moutli  or  tiie  intestines — apart 
from  a  weakening  of  the  germ  in  the  stomach — depends  upon  the 
rapidity  of  their  passage.  Fluids  will  more  easily  afYect  the  intes- 
tines;  solid  foods,  which  have  to  be  masticated,  or  micro- 
organisms, accidentally  introduced  into  the  mouth  by  the  fingers 
or  other  objects,  and  whicli  need  no  special  act  of  swallowing  and 
remain  longer  in  the  mouth,  are  more  dangerous  to  the  buccal 
cavity. 

Oehlecker    gives   a    striking    example  :    ''  Bc^nbons,    and    the 


140  sc'Roi  rn)sis 

affect  ioiiaie  con.suinpii\  c  tricnd,"  mu'  who  iH-iaiiu-el  lill  shortly 
before  her  death  the  appetizing  custom  of  allowing  chiUlren  to 
lake  bonbons,  chocolates,  .^c,  out  of  her  nioulh,  whereby  three 
children  developed  tuberculous  glands. 

The  fips,  tonsils,  and  carious  teeth  are  fa\-ouriie  sites  of 
scrofulous  infection,  the  lips  because  diey  are  exposed  to  con- 
laniinaiit)n.  especially  in  children  who  use  them  for  cleaning  their 
soiled  lingers,  and  which  hold  dirty  objects  put  info  ilu-ir  mouths, 
such  as  trumpets,  baljy  comforters,  (S:c. 

Waldever's  pharxngeal  area  is  very  im]:)ortant  in  infection  as, 
being  speciallv  adapted  for  the  retention  of  foreign  l)otlies  wliich 
mav  have  penetrated  owing  to  its  abundance  of  lymphoid  tissue 
(Freudenthal  and  others),  it  may  be  looked  upon  as  a  series  of 
achancetl  ramj^arts  and  trenches. 

The  tonsils  are  especially  titled  for  the  absorption  of  germs 
bv  reason  of  their  pilled  structure,  which  gives  a  hold  to  infec- 
tious panicles,  bv  their  defective  sieve-like  epithelium  (Stohr),  and 
by  tliQ  close  contact  into  which  they  enter  in  the  act  of  swallow- 
ing with  all  the  ingesta  passing  down  the  oesophagus ; 
Dmochowski  even  attributes  suction  properties  to  the  crypts. 
Goodale  and  Mendelsohn  established  these  facts  by  various 
powders  of  tine  substances,  carmine,  and  soot  which  penetrated 
the  tonsils.  Pirera  used  pus  cocci ;  Lexer  brushed  on  virulent 
streptococci.  Hypertrophv  of  the  tonsils  is  a  regular  accompani- 
ment of  scrofulosis. 

Respecting  tuberculosis,  the  researches  of  Strassmann, 
Schlenker,  Dmochowski,  Kriickmann,  Walsham,  Scheibner, 
Escomel,  Schlesinger,  Grawitz,  &c.  (Cornet,  "  Die  Tuberculose," 
second  edition,  p.  223)  have  shown  that,  when  the  opportunity 
of  infection  is  caused  bv  a  large  number  of  tubercle  bacilli,  the 
tonsils  are  alwavs  attacked  in  the  course  of  advanced  consumption, 
that  under  such  circumstances  frequent  occurrences  of  tonsillar 
tuberculosis,  sometimes  accompanied  by  tuberculous  swelling  of 
the  glands,  have  misled  certain  authors  into  claiming  the  neck 
glands  to  be  almost  the  only  point  of  entry  of  the  tuberculous  virus. 

That  tuberculosis  of  the  tonsils  is  a  primarv  disease  has  been 
shown  by  Schlenker,  Kriickmann,  Orth,  Goerdeler,  Ito,  in  single 
cases;  b\-  Friedmnnn  five  times  in  ninelv-one  tonsils  of  children 
after  death,  and  by  Lubarsch  in  twelve  cases. 

Clinically,  Abraham  found  apparent  tuberculosis  of  the 
tonsils  (in  a  scrofulous  woman);  Hopkins,  Sacaze,  Ruge, 
Hofmann  relate  similar  cases  (in  the  last  case  the  patient,  aged  18, 
was  accustomed  to  use  the  pencil  of  her  consumptive  neigh- 
bour and  to  bite  her  finger-nails);   Kingsford,   among  se\-enteen 


(JKNI'ISIS     OI<-     SCKOI'CI.OSIS  •  14I 

children  willi  swollen  (crvical  glands,  lininiJ  1  uhereulosis  <>\  ihe 
tonsils  in  sf\cii  cases,  \)\\\  all  iliese  cases  together  are  n(jl  nnnier- 
ons,  and  go  lo  Ualancc  I  ic(|iiciii  iicg,-ii  i\c  lnulings. 

in  the  sani(i  way  l'"riedniann  never  lonnd  liibercnlosis  of  the 
tonsils  among  forty-six  living  children  witli  liyi)erlnj])hy  ol  the 
tonsils  and  pharyngeal  tonsils,  and  among  six  children  with 
decided  tuberculosis  of  glands  (excepting  in  f)ne  child  who  showed 
evidences  of  lung  disease).  Ito,  among  104  children,  found  after 
death  secondarv  liiberculosis  of  ilu-  tonsils  li\c  limcs,  but  no  case 
of  primary  tuberculosis  (see  also  p.  \ot,). 

]3andelier,  among  200  hypertrophied  tonsils  wliif  li  had  been 
removed  in  luberculous  jiersons,  and  eight  pharyngeal  tonsils, 
established  tuberculosis  in  ten  cases;  only  two  cases  were 
apparently  primary  tuberculosis. 

Tarchetti  and  Zanconi  obtained  negative  results  in  fourteen 
cases  during  life  by  inoculation  of  hypertrophied  tonsils  and 
vegetations.  Escomel  had  the  same  result  in  eleven  non- 
tuberculous  persons  during  life. 

Dieulafoy  produced  tuberculosis  only  eight  times  by  injection 
of  tonsils  in  sixty-one  guinea-pigs. 

V.  Scheibner,  in  sixty  tonsils  which  he  examined  histologi- 
cally, declared  four  to  show  probably  primary  tuberculosis,  but  he 
also  declared  that  he  could  not  obtain  an  entirely  convincing  proof 
of  the  existence  of  primary  tuberculosis  of  the  tonsils. 

In  the  face  of  results  wliich  have  hitherto  been  produced,  we 
are  not  justified  in  attaching  any  great  importance  to  the  tonsils 
in  tuberculosis  or  scrofulosis  of  the  cervical  glands,  to  say  nothing 
of  making  theni  almost  entirely  answerable  for  their  causation. 

Without  denying  their  considerable  importance  in  scrofulosis, 
we  have  no  ground  for  considering  the  permeability  of  all  other 
parts  of  the  mucous  membrane,  which  has  once  and  for  all  been 
established  as  of  no  special  importance  in  conditions  which  come 
before  us  in  practice,  and  which  does  not  now  and  again  give 
rise  to  actual  infection. 

Rosenberger,  among  nineteen  cases  of  severe  tuberculosis 
with  suppurating  glands,  found  in  nine  cases  no  hypertrophy  of 
neck  area,  and  no  tuberculosis  macroscopically. 

This  exclusive  point  of  view  has  been  refuted  by  the  fact 
that  the  cervical  glands  connected  with  the  tonsils  are  not  always 
primarilv  affected,  but  often,  in  about  one-third  of  the  cases,  there 
is  quite  a  dift'erent  zone  of  absorption. 

The  pharvngeal  tonsils  form  by  their  irregular,  uneven 
structure  a  favourable  spot  for  the  collection  of  bacteria,  especially 
tubercle   bacilli.       In    the   vault   of   the   pharynx   the   respired  air 


14^ 


SCROI'LLOSIS 


undergoes  a  change  i>f  direction,  and  tin-  bacieria  contained  in  n 
are  diVecilv  projected  on  lo  ihe  tonsils;  the  cihaied  cpithcUnm, 
the  office  of  which  is  to  provide  for  their  further  progress,  is, 
especialh  in  voung  persons,  often  replaced  by  sc|uanious  epuhe- 
Hum  (Dmochowski),  and  is  damaged  in  its  functional  capacity  by 
frequent  inflammation. 

The  occurrence  of  tuberculous  disease  ot  the  pharyngeal 
tonsil  is  verv  varioush  estimated.  Main  writers  do  not  record 
it  once  in  loo  cases;  others  record  S,  or  even  jo  per  cent, 
(see  Suchannek,  Dmochowski,  Koschier,  Brieger,  Lewin  and 
Gradenigo). 

Mv  rcsuiuc  of  the  works  of  I.ermoyez.  Goltstein,  Brindel, 
Broca.  Pluder  and  Fischer,  (iourc,  Bride  and  'riirner.  llynitsch, 
Luzzato.  Piffl.  Pilliet,  Wright,  Brieger  and  Lewin,  Ilo,  Wex, 
Uffeni)rde,  Poliakov,  Rethi,  Baup,  Cornil,  Zwillinger  showed 
tuberculosis  71  times  in  1,745  cases  (41  per  cent.);  I.achmann 
found  in  a  later  collection  of  2,065  eases  89  cases  of  tuberculosis 
(4-3  per  cent.);  Cahn  found  tuberculosis  of  the  pharyngeal  tonsil 
in  4  per  cent,  of  persons  affected  with  adenoids  (see  also  Barstow, 
Escomel,  Ivens,  Lachmann).  These  figures  reduce  the  ex- 
aggerated ccmception  of  the  pharyngeal  tonsil  to  a  more  modest 
proportion   (Trautmann,   jessel,   Zarniko,    Beckmann). 

A  good  number  of  swellings  belong  to  the  non-lubercular 
form  of  scrofulosis. 

Nebecourt  and  Tixier  found  quantities  of  adenoids,  hyper- 
trophied  tonsils,  and  enlarged  glands  in  twenty-tw-o  children,  but 
nothing  of  a  tuberculous  nature  (see  also  Simon,  and  others,  p.  195). 
The  glands  of  the  lingual  follicles  and  the  other  divisions  of 
the  tubal  prominences  of  the  pharynx  seldom  form  an  entrance  for 
bacteria. 

Zickgraf's  investigations  do  not  sui^porl  the  hypothesis  ]:)Ut 
forward  bv  Freudenthal  respecting  the  lingual  tonsils  as  a  point 
of  .entry  for  tuberculosis. 

Apparently  the  cavities  of  carious  teeth  are  a  focus  of  infec- 
tion, oftener  than  has  hitherto  been  admitted.  In  the  last  few 
years  Odenthal,  Hoppe,  Berten,  Starck,  and  Kdrner  have 
especially  called  attention  to  the  connection  of  carious  teeth  with 
chronicallv  swollen  neck  glands  or  hyperplastic  lymphomata. 

Among  700  children  with  enlarged  neck  glands  in  whom 
Odenthal  examined  the  teeth,  346  were  found  with  carious  teeth, 
and  no  other  manifest  cause  for  the  enlarged  glands,  79  with 
caries  and  other  simultaneous  affections  at  the  roots  of  the  teeth 
which  could  be  considered  as  the  cause.  In  175,  gaps  between 
the  teeth  showed  the  former  existence  of  decaved  teeth.     Accord- 


(;|';nI':s[.s   (>\'    sckoimi.osis  143 

in<4'  lo  kosciii  lial,  sonx'  .'iricclidii  nl  ilic  icfih  w.-is  llic  causf;  ni  ^o 
lo  60  per  ccnl.  ol  (•nl,-ii'<;*-(l  cervical  glands  (sec  .-il.so  Anscliiil/). 
As  I'arlscli  pninlcd  mil  willi  caries,  ciil'i  it_;c(|  i^l.-inds  in  tlif  necl< 
only  occur  when  llie  process  has  invaded  \\\c  pidp  and  .uK'anced 
lo  (he  roots  of  ihe  leeMi.  l'"roni  s\iiipadi\-  die  siihinaxillary  and 
SLihmenlal  j^lands  become  sj)ecialiy  invoked. 

The  siniiihaneous  occurrence  of  caries  and  affecied  ^dands  does 
no(  warrani  of  ilseh  an\'  causal  conneclion,  and  from  llie  al)o\e 
figures  il  is  nol  perceplible  how  far  ihe  oc(  iirrence  of  ihe  r-nlar^^ed 
elands  can  hi'  idenlified  wiMi  scrofiiln.sis.  A  near  conneclion, 
however,  cannol  be  denied,  sin<e  die  exisleiKe  <,\  iiiberele  bafilli 
in  carious  leelh  has  often  l:)een  proved,  and  a  j^'land  tuberculosis 
following'  it  has  been  fre(|uenlly  confirmed,  ((jrawilz,  I 'n^'-ar, 
Slarck',  Moorehead,  and  others). 

Partsch  informs  us  of  a  case  of  lul)erculous  perif)dontitis  in 
a  carious  tooth  with  infection  of  the  neighliouring  cervical  glands. 
Killer  and  Miiller  relate  a  similar  case;  the  suspicion  of  the  tuber- 
culous character  is  especiall}'  justified  by  the  further  progress  of 
the  gland  processes.  Hoppe  says  that  Ik^  has  found  tubercle 
bacilli  in  recently  extracted  carious  teeth  six  limes  in  sixteen  cases, 
and  in  the  excav'ated  decayed  substance  seven  times  in  eleven 
school  children,  and  ten  times  in  the  saliva  and  sordes  on  the 
teeth  of  twenty  school  children.  It  must  remain  undecided 
whether,  on  looking  back  on  this  astonishing  result  and  the  want 
of  further  proof,  <:'.,:;■.,  by  injection  tests,  an  interchange  with 
other  acid-fast  bacilli  (smegma  or  butter  bacillus)  must  be 
admitted.  Korner  twice  found  tubercle  bacilli  after  testing  twentv 
persons. 

JMoeller  found  tubercle  bacilli  six  times,  and  pseudo-tubercle 
bacilli  eighteen  times  in  forty-one  cases  of  sordes  of  the  mouth 
in  healthy  school  children.  In  194  school  children  with  lung 
disease,  in  133  carious  teeth  he  found  tubercle  bacilli  fourteen 
times,  and  pseudo-tubercle  bacilli  twenty-three  times;  in  182 
mouth  secretions  tubercle  bacilli  thirtv-tive  times,  and  pseudo- 
tubercle  bacilli  forty-two  times. 

The  wound  caused  by  tooth  extraction  was  considered  bv 
Doutrelepont  to  be  the  point  of  entr}-  of  tubercle  bacilli  (see  also 
cases  by  Schlieferowitsch,  Neumayr,  Lenzmann,  Ehrhardt 
[?  infection  by  dentist's  instruments]). 

Besides  carious  teeth  in  dentition,  the  rupture  and  loosening 
of  the  epithelium,  an  inflammation  of  the  gum  or  irritation  from 
the  formation  of  tartar,  lead  to  the  admission  of  germs. 

But  when  Westenhoeffer  says  that  perhaps  the  greater 
number    of    cases    of   tuberculosis    in    children    (not    onlv    single 


J  44  SCROFLLOSIS 

scrofiil()-iul)erculous  glands)  are  to  be  traced  to  infection  iliroiigh 
injuries  connected  with  dentition  it  is  noi  substantiated  by  any- 
thing, and  the  infrequency  n\'  regional  gland  enlargement  in 
teething,  anel  according  to  Most  ilic  stanu  delicate  lymph  channels 
in  the  stretched  ah'eolar  mucous  membrane,  contradicts  ii. 

In  the  eve  staphylococci  and  tubercle  bacilli  (as  has  been 
repeatedly  demonstrated)  in  such  i)rocesses  are  introduced  chiefly 
bv  dirtv  lingers,  handkerchiefs  and  towels,  coughing  and  kissing, 
Manv  of  the  germs  thus  implanted  are  rendered  harmless  by  the 
property  which  the  tears  possess  of  checking  their  growth  and 
are  c|uickly  remo\ed  by  the  flow  (»t  icais. 

I'^oreign  bodies  purposeh'  iniroiluccd,  su(  h  as  so-called  "  vye 
stones,"  and  the  bad  practice  ciisiomary  in  many  places  of  licking 
the  eve  (Pregel)  or  smearing  with  salixa,  are  modes  ^)\'  inieclion, 
though  perhaps  not  in  frecjuent  use. 

The  swelling  of  the  pre-auricular  and  subauricular  glands 
with  those  of  the  maxillary  and  neck  glands  especially  points  to 
this  source  of  infection  (Haab,  Most). 

The  very  large  area  from  which  the  neck  glands  deri\e  ilicir 
Ivmph,  including  the  skin  of  the  face  as  well  as  the  mucous 
membrane  of  the  mouth,  nose,  ears,  and  eyes,  explains  the  great 
frequency  of  affections  of  the  cervical  glands. 

Of  the  other  mucous  membranes  which  communicate  with 
the  body  surfaces  and  from  which  exogenous  infection  can  be 
derived  we  find  in  the  anus  in  early  infancy  the  fewest  derange- 
ments. 

In  the  genital  mucous  membranes  there  is  often  in  early 
childhood  irritation  dui'ing  the  process  of  cleansing  and  more 
often  than  is  usually  supposed  for  other  purposes  by  unprincipled 
]3ersons.  The  frec|uency  of  true  gonorrhccal  affections  in  little 
girls  with  proofs  of  the  gonococcus  furnishes  the  sad  e\"idence  that 
in  diseases  of  the  vulva  and  vagina  in  children  we  must  seek  the 
source  not  in  a  special  predisposition  of  this  mucous  membrane, 
but  in  the  first  instance  in  the  uncleanliness  or  in  the  sexual 
aberrations  which  are  prevalent  in  their  environment ;  often  in 
poor  districts  the  close  association  at  night  of  children  with 
lodgers  gives  opportunities.  Besides,  an  opportunity  of  infection 
presents  itself  in  onanism,  which  not  infrequently  occurs  in  quite 
little  girls.  "  It  is  hard  to  believe,"  says  Henoch,  "  that  little 
children,  2  years  old  and  even  younger,  masturbate,  either  by 
actual  manipulation  or  by  rubbing  the  thighs  together,  and  often 
bv  rhythmical  swaying  of  the  body  when  in  a  sitting  posture." 
Nursemaids  often  give  encouragemeni  lo  iln's  when  for  their  own 
amusement  or  to  quiet  a  crying  child  ihe\-  play  with  the  genitals. 


(;i;ni:sis   of   sckomh-osis  145 

'riu*  forei^m  bodies  vvliidi  :\vc  oticn  removed  from  I  lie  child's 
vaj^-ina  (hairpins,  slicks  ol  se;diii^-\v.'i,\,  necdjc-casr-s  anci  foriy- 
two  pel)l)les  in  Ihecase  of  a  girl  aged  \())  afford  finiher  evidence  of 
llie  mode  of  infeclion  in  such  alTeclions  of  die  genilals  and  the 
enlargemeni  of  die  ii(iL;hl)oiiring  lymphatic  glands. 

Wild  observed  six  cases  of  iiiber(  ulosis  \ei-rucosa  and  one  of 
lupus  in  children  of  3  to  12  years  of  age  near  the  genilals,  where 
children  rub  the  chamber  in  silling,  and  he  suspecled  a  contamina- 
tion with  spuliim  or  tuberculous  molions.  in  a  girl  aged  3 
primary  tuberculosis  of  the  vulva  was  produced  by  sliding 
about  on  the  ground  in  the  room  of  a  tuberculous  neighbour 
(1  lamburger). 

Scrofulous  changes  in  bones  and  in  various  internal  (jrgans 
arise  on  account  of  their  position,  sh.ut  off  fr(^m  outward  con- 
nections, not  by  exogenous  infection,  but  doubtless  without 
exception  by  a  focus  existing  already  in  the  body.  Albrecht  has 
collected  325  cases  of  fungous  joint  inflammation,  of  which  he 
attributed  a  third  to  scrofulosis.  Rupprecht,  Sprengel,  &c.,  have 
referred  to  scrofulous  diseases  of  the  skin  and  sense  organs  as 
the  starting-point  of  bone  and  joint  infection. 

About  a  third  of  bone  and  joint  diseases  occur  in  the  first 
ten  years  of  life,  the  time  when  gland  affections  are  most  frequent 
and  the  tendency  to  a  generaHzation  of  tuberculous  processes  is 
most  pronounced.  Half  of  all  the  cases  occur  during  i  to  20  years 
of  age  (Billrotli).  The  primary  focus  generally  lies  in  the  glands, 
and  not  onlv  in  the  easily  noticeable  cervical  glands  but  probably 
more  often  in  the  deeper  seated  bronchial  and  mesenteric  glands ; 
to  this  may  be  attributed  the  frequent  and  apparently  primary 
formation  of  the  focus  in  bone.  Direct  infection  from  the  adjacent 
skin  must  ahvavs  be  kept  in  mind  in  the  case  of  superficial  bone 
foci,  as  was  perhaps  the  case  in  that  mentioned  by  !MiddledorfT,  in 
which  a  lad  aged  16  injured  himself  bv  a  blow  of  a  hatchet,  bound 
it  up  with  a  pocket  handkerchief,  and  later  tuberculosis  of  the  knee- 
joint  occurred.  The  focus  is  often  very  small  and  defies  the  most 
careful  anatomical  examination.  Should  bacteria  enter  the  blood- 
stream from  such  a  focus  they  would  be  deposited  just  as  the 
other  corpuscular  elements  suspended  in  it,  more  especiallv  in  the 
marrow  and  also  in  the  liver.  It  is  to  be  supposed  that  for  tuber- 
culosis of  the  spine,  ribs  and  sternum,  which  represent  about  a 
third  of  all  scrofulous  bone  affections,  the  genesis  is  (besides  the 
lymph  passages)  from  the  neighbouring  bronchial  glands;  for 
the  pelvis  and  hip-joint  from  the  mesenteric  glands.  Scrofulosis 
of  the  bones  and  joints  thus  forms  a  later  stage  of  scrofulous 
disease  and  will  therefore  be  treated  of  further  on. 

10 


CHAPTER    IV. 

INFECTIOUSNESS    OF   SCROFULOSIS 
(SPREAD  OF  THE  DISEASE.) 


The  associaiion  of  bacteria  in  scrofulusis  j^ives  it,  in  con- 
sequence, a  certain  j)i)\\cr  ot  infection.  The  obserxation  ot  the 
various  metastases  of  scrofulous  material  within  the  body,  the 
successive  transference  of  the  disease  from  gian'd  to  gland,  from 
organ  to  organ,  leads  one  to  the  idea  of  infectiousness. 

For  a  long  time,  especially  since  scrofulosis  and  tuberculosis 
were  identified,  or  at  least  accepted  as  being  related,  its  infectious 
nature  was  affirmed  and  found  supporters  in  Baumes  and  others, 
at  least  for  the  more  severe  forms ;  he  warns  us,  for  example, 
against  using  instruments  that  have  been  used  for  scrofulous 
persons  for  non-scrofulous  patients.  But  Lugol  (1845),  who  only 
recognizes  the  effects  of  heredity  everywhere,  contests  the  con- 
tagiousness both  of  scrofulosis  and  tuberculosis,  referring  to  the 
attempts  of  different  investigators  to  transfer  the  disease  to  dogs 
and  men  by  means  of  scrofulous  pus,  as  these  attempts  up  to  that 
time  had  been  followed  by  negative  results.  These  experiments 
are  now  of  little  value  in  view  of  the  many  positive  inoculations 
and  were  clearly  badly  managed. 

It  is,  however,  from  Lugol 's  works  that  we  see  how  wide- 
spread was  the  conviction  of  the  contagiousness  of  scrofulosis 
among  doctors  and  laymen  even  at  that  time.  For  after  a  question 
concerning  this  had  been  asked  by  the  Parliament  in  Paris  of  the 
medical  faculty  there,  and  had  been  answered  in  the  affirmative, 
and  after  discussion  had  taken  place,  an  edict  was  issued  which 
led  to  precautionary  measures  being  taken.  The  remark  of 
Lugol,  an  opponent  of  the  theory  of  contagion,  is  interesting  in 
that  he  said  that  scrofulosis  had  become  very  frequent  in  Nice 
since  so  many  people  suffering  from  pulmonary  tuberculosis  had 
been  sent  there — a  historical,  and  in  this  case  an  ingenious  testi- 
mony opposed  to  the  contradictory  statements  from  health  resorts 
and  institutions  of  to-day. 

In    infection    we   must    distinguish  between    closed    foci  and 


JNl'KC/IKJUSNKSS    Ol'     S(  KOI  I,  I.OSIS  I47 

supcilici.'il    loci,    or   siicli    .'is  arc    in    .-my   way   connitcAcd    witli    lli'- 
surlaci^  by  llicir  sccrcl  ioii.s. 

A.  clisscniiilalion  ol  gcrin.s  iiai  iirall)  (aiiiiol  lak'c  ])U\<  <■.  troiii 
closed  foci,  eilhcr  in  I  lie  neck,  bnjncliiai  or  iDcsenleric  glands,  or 
in  bones  and  joints,  of  whatever  naUin-  ihcsc  may  be.  As  such 
foci  fill  numerically,  and  as  regards  duration  a  large  space  in  the 
clinical  picture  of  scrofulosis,  ilic  inlcciioiisncss  of  the  disease  is 
thereby  much  reduced. 

In  superficial  and  open  lo(  i  ihr  dcgrcf;  of  infection  depends 
principally  on  (he  nalnre  of  die  causative  agent  of  the  disease 
whether  we  have  U)  do  with  pyogenic  bacteria  or  tubercle  bacilli. 

A  secretion  containing  tubercle  bacilli  which  is  discharged 
from  a  ruptured  gland  or  bone  fistula  and  open  abscesses  is  just 
as  dangerous  under  certain  circumstances  as  tuberculous  sputum 
to  the  environment  of  the  jDaticnt  and  more  especially  to  the 
patient  himself.  Dried  and  pulverized  on  the  body  or  on  dressings 
it  is  a  source  of  danger  to  the  respiratory  tract  and  its  glands, 
also  either  moist  or  dry  and  when  mixed  with  food  it  is  a  danger 
to  the  intestine,  and  in  children  leads  to  tuberculosis  of  the  mesen- 
teric glands.  It  threatens  the  other  glands  by  contact,  as  I  have 
shown  in  the  illustrative  cases  cited  in  the  second  edition  of  my 
book  on  "  Tuberculosis." 

In  consequence  of  the  anatomical  construction  of  the  child's 
skin  such  infection  in  the  case  of  the  younger  brothers  and  sisters 
of  our  young  patients  frequentlv  takes  the  form  of  an  affection 
of  the  glands,  of  scrofulosis,  by  which  an  impression  of  a  familv 
peculiarity  may  easily  give  rise  to  a  pseudo-hereditv. 

The  extent  of  the  danger  of  infection  from  a  tuberculous 
scrofulous  patient  varies  greatly  in  individuals.  It  is  clear  that 
a  scrofulous  patient  with  a  scanty  quantity  of  pus,  poor  in  bacilli, 
is  as  a  rule  not  so  great  a  source  of  danger  to  his  environment 
as  a  person  suffering  from  phthisis  who  is  careless  with  his 
expectoration.  Anyone  who  would  take  the  trouble  to  ascertain 
the  quantity  of  bacilli  dispersed  in  the  one  way  and  the  other 
would  get  a  statistical  table  of  the  matter.  Exceptions  occur  to 
this  rule,  but  that  a  person  suffering  from  phthisis  mav  disperse 
few  bacilli  and  a  scrofulous  patient  many  does  not  affect  the  fact. 

The  demonstration  of  virulent  bacilli  in  scrofulous  and  tuber- 
culous persons  respectively  shows  that  there  is  a  possibility, 
even  if  remote,  of  their  spreading  such  infections. 

A  person  hitherto  in  health  can  also  be  infected  from  the  pus 
of  pyogenous  scrofulosis  in  the  same  way  as  from  anv  other  pus 
focus,  and  children  naturally  more  easily  than  adults. 

But  one  single  transmittance  is  not  followed  by  die  whole 
complex  of  symptoms  of  scrofulosis  as  mi£;-ht  be  the  case  with 


148  scRoiri.osis 

the  tubercle  bacillus.  It  a  child  have  the  anatomical  qiialilicaiions 
above  described  of  skin,  mucous  membrane  and  lymphatics,  inter- 
course with  a  scrofulous  patient  who  disseminates  notoriously 
virulent  pus  cocci  can  be  an  essential  excitant  of  actual  disease. 

The  question  whether  scrotulosis  can  be  iransmilled  by 
vaccination  was  much  discussed,  and  was  answered  in  the  aflirma- 
live  bv  the  opponents  of  vaccination.  But  hitherto  this  has  not 
been  confirmed  by  any  conclusive  obserxation.  On  the  (onlrary, 
Baginskv  emphasizes  the  fact  that  in  many  thousand  vaccinations 
he  had  never  observed  a  spread  of  scrofulosis  by  means  of 
vaccine.  X'accination  is  menlicncd  by  some  atithors  as  beint^-  the 
exciting  agent  of  lymphatism  or  the  non-tuberculous  form  of 
scrofulosis  respectivelv.  A  transmission,  as  far  as  the  tuberculotis 
form  is  concerned,  is  hardily  to  be  ihoiigiil  of  (see  G.  Cornel, 
"  Die  Tuberculose,"  second  edition,  p.  213)  even  theoretically, 
because  as  a  rule,  excepting  in  miliary  ttiberculosis  and  very 
advanced  pulmonarv  tuberculosis,  no  bacilli  are  foiuid  in  ilic  blood 
and  Ivmph.  In  the  case  of  miliar}-  tuberculosis  children  cannot 
be  taken  into  consideration  as  they  do  not  form  the  majority  of 
those  vaccinated.  Statements  to  the  contrary  are  based  either  on 
bad  observation  or  may  be  traced  to  accidental  contingencies. 
Bierdert  gives  us  a  striking  example  of  this;  he  says,  on  a  certain 
dav  which  had  been  arranged  he  was  prevented  from  xaccinating 
a  child ;  when  it  was  brought  a  week  later  a  general  eczema  had 
broken  out  in  the  interval  which  would  certainly  have  been  put 
down  to  the  vac(~ination  if  it  had  taken  jDlace  at  the  ap]3ointed 
time.  Since  calf  lymph  has  come  more  into  general  use  and  the 
health  of  the  calf  from  which  the  vaccine  has  been  taken  can  be 
ascertained  by  immediate  autopsy  the  question  loses  its  impor- 
tance. One  thing,  however,  must  not  be  contested,  namely,  that 
by  carelessness  and  insufficient  cleanliness  micro-organisms  do 
enter  the  vaccination  wound  ;  not  infrequently  these  may  produce 
local  affection  and  swelling  of  the  glands.  But  that  has  nothing 
whatever  to  do  with  the  nature  of  the  vaccine.  The  appearance 
of  lupus  and  changes  resembling  lupus  on  the  vaccination  scars 
as  Bosnier,  Demme,  Sec,  mention,  does  nol  depend  on  llic 
vaccination,  but  is  caused  by  after-infection. 

The  apparently  frequent  finding  of  tubercle  bacilli  in  the 
blood,  not  only  of  those  suffering  from  advanced  phthisis  but  in 
initial  early  cases,  and  even  in  persons  who  seem  to  be  healthv, 
leads  us  to  suspect  some  palpable  source  of  error,  one  of  which 
we  already  know  to  be  the  presence  of  acid-fast  bacilli  in  the 
diluting  fiuid  or  in  the  water  or  the  pipes  conveying  it  (Brehm, 
Beitzke.  Schern  and  Dold,  see  p.  248). 


ci-iap'JI":r  v. 
HEREDllY. 


TiiK  supposition  that  scrofulosis  is  an  hereditary  disease  has 
formed  the  Alpha  and  Omega  of  its  etiology  for  many  autliors 
for  centuries.  Many  simply  revel  in  relating  tlie  hypotheses 
according  to  which  scrofulosis  may  be  handed  on  from  parent 
to  child.  The  representati<m  of  heredity  as  an  axiom  accepted 
from  lime  immemorial  and  liie  conflicting  opinions  of  our  days 
renders  a  closer  criticism  of  this  theory  desirable. 

Lugol  considers  heredity  as  "  the  sole  and  general  cause 
which  we  can  demonstrate  "  ;  he  grants  no  exxeption  to  the  law 
of  heredity.  According  to  him,  scrofulosis  is  a  legacy  to  the 
children:  (i)  When  the  parents  are  scrofulous;  (2)  when  the 
parents  suffer  from  lung  disease,  for  tuberculosis  prevails  amongst 
half  of  those  who  suffer  from  scrofulosis ;  (3)  if  the  parents  were 
formerlv  scrofulous  but  now  heallhv;  (4)  in  healthy  parents  whose 
brothers  and  sisters  are  scrofulous  ;  (5)  if  the  parents  were  syphilitic 
or  given  to  excess  in  venere  (either  "  the  semen  may  not  have 
remained  long  enough  in  the  seminal  vesicle  or  external  irritation 
has  preceded  the  coitus  and  therefore  the  semen  and  its  products 
have  lost  their  force  ") ;  (6)  from  parents  who  have  performed  the 
act  of  reproduction,  either  too  earlv,  before  the  25th  year,  or  too 
late,  the  man  after  52  the  woman  after  40,  therefore  with  not 
fully  developed  powers  or  po^^•ers  already  weakened ;  (7)  when 
there  is  a  great  difference  of  age  between  the  parents ;  (8)  with 
paralytic,  epileptic,  insane,  or  half-impotent  parents. 

Other  authors  consider  alcoholism  in  the  parents  answerable, 
mercurialism,  near  relationship,  and  especially  diseases  in  feeble 
constitutions.  Birch-Hirschfeld  mentions  diabetes,  leucaemia, 
malignant  tumours,  exophthalmic  goitre,  &c. 

If  we  were  to  accept  Lugol's  theories  we  should  have  so  manv 
possibilities  of  inheritance  that  we  should  never  be  at  a  loss,  even 
with  non-scrofulous  children,  of  finding  one  which  fitted,  especially 
as  Lugol  offers  the  supposition  of  adulterous  intercourse  for  all 
cases,  but  this  is  difficult  of  coniirmation  on  account  of  the 
delicacv  of  the  qtiestion. 


150  SCROFULOSIS 

In  o}>po.silion  lo  ilu-  clisciplfs  of  licrcdiiy  cloclors  have  in  al' 
times,  ever  since  this  term  has  been  used  in  a  sense  nearly  resem- 
bUng  that  of  the  present  day.  come  lo  very  dilTerent  resuhs  on 
the  ground  oi  their  clinical  observations.  For  example,  Th. 
White  (1788)  contested  the  lieredity  of  scrofulosis,  and  said  it  was 
the  same  as  if  we  should  say  that  the  children  of  lead-workers, 
who  also  work  in  lead,  i;el  lead  poist)ning. 

Leberl  (whose  book  on  "Scrofulosis"  is  even  now  worth 
consideration  bv  reason  of  llie  sharp  criticism  lo  which  it  has 
been  exposed)  especiallv  attacks  heretliiy,  which  he  considers  to 
be  not  the  chief  cause,  but  only  one  of  the  conditions  under  which 
scrofulosis  will  be  found  with  comparative  frequency.  "  Strictly 
speaking,"  savs  Leberl,  "only  this  is  certain,  llial  a  number  of 
scrofulous  and  tuberculous  jjatients  have  children  who  suffer  from 
the  same  affection  as  themselves.  It  is  better  lo  rely  on  insufficient 
but  real  facts  than  to  hide  one's  ioudrance  under  hy|:)otheses  and 
high-sounding  sentent-es." 

Birch-IIirschfeld.  who  considers  heredity  as  one  of  the  most 
important  etiological  factors,  was  obliged  to  admit  that  it  cannot 
be  confirmed  bv  statistics. 

We  must  endeavour  in  our  di\  ision  into  the  pyogenous  and 
tuberculous  form  of  scrofulosis  lo  keep  the  two  distinct,  also  in 
considering  the  question  of  heredity. 

THE   INHERITANCE  OF  TUBERCULOSIS. 

The  inheritance  of  the  tuberculous  form  of  scrofulosis  must 
be  considered  in  the  same  light  as  the  inheritance  of  tuberculosis 
itself.  We  distinguish  congenital  tuberculosis  as  a  transmission 
of  the  germ  itself,  which  may  be  either  germinative  or  placenta! 
transmission  of  the  bacilli  as  well  as  the  transmission  of  a  certain 
tendencv  or  disposition  to  tuberculosis;  heredity  in  the  proper 
sense  of  the  term,  according  lo  ]\Lariius. 

TRANSMISSION   OF  THE  GERM. 

Our  researches  on  tuberculosis  (see  the  detailed  account  of 
the  question  of  Heredity  in  my  book,  "  Die  Tuberculose,"  second 
edition,  pp.  432-476)  lia\e  vielded  tlu^  following  results  :  — 

Germinati\-e  transmission.  A  germinal  i\-e  transmission  on 
the  part  of  a  tuberculous  father  presupposes  that  tubercle  bacilli 
are  to  be  found  in  the  semen.  The  positi\-e  finding  of  the  tubercle 
bacilli  in  the  semen,  testicles,  and  seminal  \'esicles  in  cadavers, 
especiallv  with  miliarv  tuberculosis,  communicated  by  Sirena  and 
Pernice,    Spano,    Jackh,    Nakarai,    Simmonds,   may   just   as   well 


III'.KCDn  Y  1.5' 

have  Ix'cn  llic  conscciiK'iK  <•  ol  disscin  iii:il  loii  ol  \>:\i  illi  m  ili'-  l>'i'iy 
before;  (Icalli,  and  ihcrrlorc  nn  (diu  liisions  can  !)<•  drawn  from 
these  cases  for  living  sexual Iv-.-m  live  hhmi. 

Besides,  llieir  importance  is  rediicd  \)y  ih'-  n<'<^^-iti\e  lindinj^^s 
of  KoliIlT  and  Wcslcrmayer,  Waltlier,  Hohrf.ldonski,  and  tin- 
relatively  rare  occurrcncr  of  primary  L,^cniial  Inhr-rculosis  in 
women,  esi)eciallv  in  pudla'  piihlicie,  in  s\)\\c  of  ilu-  well-known 
sexual  activity  of  iliousandsof  men  suffering-  from  plidiisis. 

Even  in  experiments  on  animals,  where  w(;  can  create  the 
most  favom-able  conditions  for  such  transmission  and  have  at 
times  inundated  the  testicles  with  enormous  doses  of  bacilli,  th.^ 
experiments  of  Cava^nis,  Gartner,  (i.  Cornet,  liinaghi  have 
testified  that  the  embryos  and  young  bred  from  such  semen  were 
free  from  tuberculosis. 

Friedman n  was  tlie  only  one  to  obtain  positive  results,  that 
is  to  say,  he  found  tubercle  bacilli  in  the  embryos,  but  the 
arrangement  of  his  experiments  was  far  removed  from  natural 
conditions,  and  these  experiments,  on  which  v.  Baumgarten,  &c., 
rely  so  implicitly,  were  not  confirmed  by  the  after-tests  of  Seige. 

The  experiments  of  Karlinski  are  also  unconvincing;  he 
inoculated  the  testicles  of  a  he-goat  with  human  bacilli  and  then 
caused  it  to  cover  a  healthy  she-goat ;  the  female  remained  healthy, 
but  the  voung  exhibited  tuberculous  foci  in  the  mesenteric  glands, 
enlargement  of  the  cervical  glands,  and  peritoneal  tuberculosis, 
a  picture  which  does  not  coincide  with  what  might  have  been 
expected  from  such  a  mode  of  transmission. 

We  arrive,  then,  at  this  result,  that  up  till  now  no  conclusive 
cases  are  to  hand  which  prove  the  possibility  of  the  transmission 
of  tuberculosis  bv  means  of  semen  containing  tubercle  bacilli,  to 
sav  nothing  of  assuming  that  such  transmission  can  take  place 
with  men  under  natural  conditions.  Bongert  expresses  a  similar 
opinion  in  his  critical  reviews,  as  also  do  Crouzon  and  Villaret. 

Placental  transmission.  The  case  is  somewhat  different  with 
placental  transmission. 

The  normal  placenta  forms  an  impenetrable  filter  to  corpus- 
cular elements  and  bacteria,  but  under  the  influence  of  various 
infectious  diseases,  accompanied  perhaps  with  high  fever,  lesions 
occur,  epithelial  defects  which  render  the  passage  of  the  bacteria 
into  the  foetal  organism  possible.  In  the  case  of  a  tub.erculous 
mother  such  a  passage  is  apparentlv  onlv  possible  if  a  tuber- 
culous focus  is  in  the  placenta  itself,  as  happens  now  and  again 
in  acute  miliary  tuberculosis.  Tuberculous  foci  in  the  placenta 
have  been  demonstrated  bv  F.  Lehmann,  Schmorl  and  Cockel, 
Auche  and  Chambrelent,    Runge,   Sitzenfrev  (among  twentv-six 


132  SCROl-l  LOSIS 

moiht-rs  suffering'  fnuii  pUu-t-nial  iiihrrcuilosis  scxcn  linu'S  wiili 
tuberculous  changesj,  Jung,  Monaco,  Schniorl  and  Cicipel  ft)und 
tuberculous  changes  nine  limes  in  iweniy  cases  of  se\ere  luben  11- 
losis  and  once  in  iiuipient  phthisis  (after  2,000  preparations,  but 
the  virulence  was  (lueslionable).  The  researches  have  been 
facilitated  bv  the  aniiformin  method,  by  the  help  of  which  Novak 
and  Ran/.el  demonstrated  tuberculosis  in  ten  placentas  seven 
times  bv  antiformin  and  three  times  histologically  (see  p.  247). 

Amongst  cattle,  placental  tuberculosis  appears  t(»  be  more 
frequent,  and  frcm  this  the  relatively  more  numerous  cases 
(according  to  Arvid  Bergman  o'42  per  cent,  of  ne\\-l)i)rn  calves 
are  tuberculous)  is  to  be  explained. 

But  even  the  tuberculous  placenta  appears,  according  to  the 
histological  findings  of  Schmorl  and  Cockel,  to  offer  in  many 
cases  a  protection  against  the  entry  of  bacilji.  Carl,  Benecke,  and 
Kiirbitz,  Ilenke,  Ilamm  and  Sclirumpf,  Schlompert  (five  cases) 
■could  find  no  tuberculosis  in  the  ftvlus  in  spite  of  placental 
tuberculosis. 

In  other  cases  of  Sclirumpf,  AVarlliin  and  Cowie,  Lobenstine 
and  Wollstein  a  transmission  of  the  bacilli  to  the  foetus  was 
consequent  upon  placental  tuberculosis. 

Whether  a  transmission  is  possible  without  tuberculous 
changes  in  the  placenta  is  doubtful  (Geipel).  Aschoff  and 
Bernard,  Courmont  and  Charier  inf(^rm  us  of  a  placenta  free 
macroscopicallv  and  microscopically,  but  tubercle  bacilli  were 
demonstrated  in  the  liver  of  the  foetus;  in  such  cases  small 
placental  foci  may  have  been  overlooked.  Bossi,  who  in  twelve 
cases  inoculated  the  placenta  and  liver  of  the  miscarried  foetus  of 
tuberculous  women,  onlv  found  bacilli  in  one  placenta  w^hich  was 
not  intact. 

But  it  might  alwavs  be  supposed  that  under  the  influence  of 
high  fever,  especiallv  in  miliary  tuberculosis,  there  may  be  breaks 
in  the  continuity,  and  it  is  just  at  these  spots  that  the  bacilli 
mav  have  entered  (see  cases  by  Schmorl  and  Birch-Hirschfeld, 
Hochsinger). 

The  actual  o(~eiu'rence  of  tuberculous  fcrluses  is  more  impor- 
tant especiallv  in  the  new-born,  in  which  tuberculous  changes 
have  been  demonstrated  so  soon  after  birth  that  the  seat  of  these 
changes  and  their  degree  of  de\'el()pment  entirelv  exclude  the 
idea  of  infection  post  partum,  which  therefore  conclusively  prove 
intra-uterine  transmission.  A  few  such  cases  in  man  which 
stand  the  test  of  critical  demands  more  or  less  were  recorded  b\^ 
Charrin,  Berti,  Sabnurraud,  Lannelongue,  \'.  Rindfleisch,  Hoch- 
singer, TTonl.  T^ugge.  AucIk-  and  Chambrelent,  TTenk'e,  Brindeau, 


lleiLz,  l.ylc,  Stockcl,  J  Iaml)iir^<T,  S(  limoil,  and  liircli-l  I  irs(  litcUl 
<(lhe  firsl  c-iuthenlicated  case,  in  nian),  Arni.-mni,  'I  liifM-(;f,'lin  and 
]^ond(',  ixcovgi,  J^itschcl,  .'ind  a  few  oIIkts. 

Gartner  has  been  able  lo  dcmonslraU;  cxixMinicnlally  in  a 
few  cases  the  presence  of  tubercle  bacilb'  in  ilie  ovum  after 
in()culatin<(  pregnant  animals  willi  a  v(?ry  large  (|uanlity  of  bacilli  ; 
also  Friedmann  and  Galbo  have  f(jund  the  sani(;  if  the  female 
were  inoculated  before  copulation. 

Jezierski  injected  tubercle  bacilli  into  animals  in  an  advanced 
stage  of  pregnancy,  and  in  half  (he  cases  the  fd'tus  j)roved  t(j 
be  tuberculous  on  inoculalion.  Naturally  such  experiments,  when 
the  body  is  inundated  with  bacilli  (which  according  to  weighi 
would  be  as  if  one  should  inject  350  grammes  of  tubercle  bacilli 
into  (he  trachea  or  il  Hires  inio  the  abdominal  caxitv),  admit  of  no 
comparison  with  natural  conditions  in  men. 

On  the  contrary,  the  inoculation  of  parts  oi  the  organs  of 
the  fa^tus  of  a  tuberculous  mother  into  man  and  animals  has  very 
frequently  had  a  completely  negative  result  :  Straus,  Xocard  (forty 
foetuses);  Galtier,  Grancher  and  Straus  (forty-nine  inoculations); 
Sanchez  and  Toledo  (sixty-five  foetuses) ;  Vignal  (eleven  fcetuses 
and  seventeen  placentas) ;  G.  Cornet  (233  ova,  partly  entire 
embryos  or  parts  of  an  organ) ;  Jaquet  could  demonstrate  no 
tubercle  bacilli  in  several  human  foetuses  of  tuberculous  mothers. 

The  possibility  of  placental  transmission  is  therefore  con- 
firmed without  doubt ;  but  of  what  account  are  the  few  (hardly 
twenty  to  thirty  cases)  which  the  most  industrious  of  pathologists 
in  all  civilized  lands  have  been  able  to  collect  in  the  course  of  the 
last  twenty  years,  against  the  100,000  new-born  children  and 
foetuses  of  tuberculous  mothers  which  have  passed  through  their 
"hands. 

Placental  transmission  is  doubtless  possible  according  to 
•clinical  and  experimental  results,  but  it  is  practicallv  unimportant, 
because  as  a  rule  it  presupposes  a  mother  yho  is  tuberculous  in 
the  highest  degree,  or  suffering  from  general  miliarv  tuberculosis. 
According  to  all  experience  hitherto  gained,  such  infected  progeny 
die  after  a  short  existence  either  from  weakness  and  atrophv  or 
from  their  inherited  intra-uterine  tuberculosis.  This  is  confirmed 
by  the  progressive  and  generally  fatal  course  of  infantile  tuber- 
culosis, besides  which,  clinical  and  anatomical  conditions  confute 
the  theory  of  placental  inheritance  of  the  germ  as  the  cause  of 
scrofulo-tuberculosis,  for  in  this  case  the  primarv  seat  of  the 
disease  is  in  the  neck,  bronchial  and  mesenteric  glands;  the 
internal  organs,  bones,  and  joints  are  only  secondarilv  attacked, 
whilst    with    placental    transmission    the    organs    which    mav    be 


'34 


SCROFl'I.OSIS 


ci  Ml  side  red  as  ihe  poiiil  of  enlry,  llie  \\\cv  and  die  inlands  oi  die 
porta  liepalica  are  lirst  aliaeked.  Furllier,  aecordin^-  lo  numerous 
results  of  p(^st-mortc)ns,  caseous  glands  only  appear  at  about  the 
second  nioniii  after  bird),  and  so  at  a  time  when  exira-uierine 
infection  niav  have  taken  jilace  ;  lastly,  experience  has  shown  that 
in  orphanages  and  foundling  hospitals,  whose  occupants  are 
descended  for  the  most  part  from  tuberculous  i:)areiits,  scrofulosis 
and  the  tuberculosis  which  in  general  follows  it  are  extremely  rare 
(I'lpstein,  (S:c.) ;  therefore  the  real  cause  is  to  be  sought  after  birth 
in  the  association  widi  affected  parents.  'Vhe  greater  fre(iuency 
of  tuberculosis  ("  Hie  Tuberculos'-,"  second  edition,  p.  4(\:;)  is  no 
contradiction,  but  is  caused  liy  faulty  hygienic  conditions  which 
fa\-our  the  transmission. 

The  experiments  of  Schreiber,  Bertheraud,  and  Behrend  are 
of  special  importance.  Ac^-ording  lo  them,  the  fact  that  tuberc-idin 
injections  in  infants  of  luliercutous  descent  was  followed  b^■  no  re- 
action, pointed  to  liereditar\-  transmission.  The  more  recent  llnd- 
ings  b\-  V.  T^'irquet's  reaction  had  almost  entirely  negati^■e  results 
in  infants  of  tuberculous  parents  (according  to  ^^loro  3  per  cent, 
were  positive;  see  also  Bondy,  Escherich,  Siegert,  &c."). 

Hitherto  for  ordinary  pyogenous  scrofulosis,  since  we  have 
separated  this  from  tuberculosis,  the  hypothesis  of  inlra-tilerine 
transmission  of  the  germ  has  not  been  e\"en  advanced. 

HEREDITARY  TENDENCY  TO  TUBERCULOSIS. 

llow  does  the  case  stand  witli  regard  to  further  proofs  of  the 
theorv  of  heredity  if  we  except  the  few'  trustworth}-  cases  of  con- 
genital tuberculosis?  If  we  deprive  it  of  its  lnpt)thetical  adorn- 
ment, belief  in  authorities,  and  the  old  purely  subjective  view 
which  has  been  "accepted  from  generation  to  generation  \\illiout 
thinking,"  the  theory  is  based  on  the  uncontested  facts  that 
children  of  tuberculous  parents  frequently — more  frequentlv  than 
others — become  tuberculous  also,  and  that  in  many  families  a 
number  of  cases  of  tuberculosis  occur  by  which  the  appearance 
of  a  family  affection  is  caused. 

All  former  works,  and,  unhappily,  most  of  the  more  recent, 
on  the  influence  of  heredity  which  are  confined  to  reckoning- 
percentages  as  to  how  often  among  the  forefathers  of  a  tuber- 
culous patient  tuberculosis  has  occurred,  are  nodiing  more  dian 
an  arithmetical  game. 

With  the  great  fre(|uency  of  tuberculosis  there  ^\()lll(l  nadirallv 
be  countless  examples  of  the  descent  of  sufferers  from  tuberculosis 
(or  tuberculo-scrofulosis)  from  tuberculous  or  scrofulous  parents. 


iiij'i.nriv  155 

'i'licsc  cases  nvc  .-ibsoliild v  110  proof  ot  lii-if(iiiar\  \cu(U-r\(y  ;  llx-y 
just  as  well  adiiiil  ol  \\\c  iiil<-i|)ri'i,-ii  ion  ol  iniHiial  iiilc*  1  ion.  (or  11 
of  two  possibilities,  liereclily  and  inleciion,  ilie  laiier  (,-mnot  he 
excluded,   (he  former  l<)<j^ically  is  noi   proxcd. 

Naliirallv,  lliose  descended  from  I  uheri  nioiis  parenis  must 
have  incr(!ase(l  ()|)p()rlunilies  ol  inhviion  on  a<(onni  of  h'ving 
closely  l<)<4'ellier  willi  llieir  I  nhiT<  ulous  relaiinns,  and  shf)\v 
fre(|nencv  ol  I  uhei'cniosis  in  an  increasi'd  dei^rpee.  So  wlial  do  llie 
slalislical  figures  produci^d  proxc  ? 

The  presence  of  luherculosis  and  serofulosis  amtjngsf  ihc 
parenis  and  broHiers  and  sislers  of  such  patients  is  in  no  way  d 
proof  of  "the  general  spread  of  the  disease  in  the  same  family," 
which,  according  to  the  famous  Lugol,  is  "  unavoidable,"  anri, 
according  to  the  no  less  famous  While,  is  "contrary  to  general 
experience." 

I  contrast  the  opinions  of  two  old  and  recognized  authors  as 
an  example  of  the  contradictory  \iews  to  whicli  ilie  subjective 
contemplation  of  the  question  leads. 

Nearlv  all  statistics  suffer  from  the  radical  fault  that  they  are 
based  on  too  scanty  material  ;  only  large  figures  are  statistically 
valuable;  only  such  give  legitimate  results  in  which  chance 
circumstances  disappear.  A  further  fault  in  such  statistics  is  that 
everything  is  thrown  pell-mell  together;  persons  who  really  are 
descended  from  parents  who  were  tuberculous  at  the  time  of  con- 
ception, and  those  whose  parents  at  the  time  in  question  were  in 
the  best  of  health,  and  therefore  could  not  pass  on  what  they  them- 
selves had  not,  if  these  parents  became  tuberculous  after  ten  or 
twenty  years,  or  even  later  after  the  birth  of  their  child,  then  tuber- 
culosis can  stand  in  no  etiological  connection  with  the  tuberculosis 
of  their  descendants.  To  every  unprejudiced  person  the  idea  that 
the  parents  were  infected  by  the  child  will  appear  more  probable. 

But  in  spite  of  these  oft-repeated  objections  (see  "  Die  Tuber- 
culose,"  second  edition,  p.  467)  recent  works  contain  such 
insufficient  calculations  and  arrive  at  quite  different  figures, 
according  to  the  material  emploved. 

F(ir  frequency  of  inheritance,  Durand  and  Gentes  give  12 
per  cent.,  Mongour  20  per  cent.,  Zilgien  32  per  cent.,  Nikolski 
50  per  cent.,  Bugajewski-Goldstein  ^2  per  cent,  sure,  and  27  per 
cent,  probable.  Sachs  mentions  that  of  the  children  of  tuber- 
culous parents  29  per  cent,  were  tuloerculous ;  Miller  and  Wood- 
ruff, that  of  150  such  children  36'S  per  cent,  were  tuberculous,  18 
per  cent,  suspected  (see  also  Oliari) ;  Dotti  found  (in  9,000  cases) 
inherited  tuberculosis  in  48" t  per  cent,  persons,  and  in  22"6  per 
cent,  of  those  sufferino-  from  exudative  diathesis.     One  mio-hr  even 


ISO  SCROl-LLOSIS 

(.loubi  if  progress  in  knowledge  would  e\er  be  obiained  whi-n  1  can 
pro\e  liie  case  of  a  well-known  siatisiician  who  on  one  page  of  his 
books  tells  us  that  a  girl  died  at  a  month  old,  and  on  the  next  page 
says  that  thirty  years  later  she  married  a  widower  and  had  seyen 
children;  antl  who  writes  of  a  person  who  is  only  born  Iwenly-four 
years  after  lier  marriage,  and  a  great  many  other  things  of  the 
same  sort  ;  an  author  whose  works  are  full  of  the  grossest  faults 
(see  criticism  in  my  "  Die  Tuberculose,"  second  edition,  p.  472), 
who  will  recognize  no  case  of  transmission  from  person  to  person, 
and  of  w  hom  Beitzke  says  that  he  is  not  to  be  taken  seriously ; 
^vhen,  in  spite  of  all  this,  he  is  quoted  without  scruple  as  trust- 
worthy by  the  believers  in  heredity,  even  by  Martin,  Kirchner,  and 
Martius,  or  his  writings  are  brought  forward  as  counter-proof  to 
other  painstaking  works. 

Of  the  \vorks  that  I  know,  that  of  Weinberg  strikes  me  as 
being  the  most  carefully  thought  out.  He  has  studied  the  subject 
in  a  series  of  thorough  investigations,  and  has  also  done  justice 
to  statistical  fundamental  laws.  He  found,  too,  that  the  children 
of  tuberculous  parents,  especially  of  tu])erculous  mothers,  died 
more  fre{|uenlh-  from  tuberculosis  than  those  of  non-tuberculous 
parents. 

Hui  more  important  is  his  further  \erilication  that  this 
hereditary  afifliction  has  al^out  the  same  influence  as  living  with  a 
tuberculous  spouse,  in  which  case  the  survivor  becomes  tuber- 
culous double  as  fre(|uenil\-  as  if  reciprocal  infection  had  not 
taken  place. 

If  conjugal  life,  which  on  account  of  its  functions  is  limited 
as  to  its  duration  with  a  tuberculous  partner,  can  of  itself  bring 
about  ilie  same  results  as  that  of  a  child  living  with  tuberculous 
parents,  what  is  left  over  for  the  influence  of  hereditary  dis- 
position ? 

Mongour  and  Thom  have  gi^•en  figures  which  about  agree 
w  ith  those  of  Weinberg. 

Burckhardt's  comparison  of  250  phthisical  patients  in  the 
hos]iital  at  Basle,  and  250  non-tuberculous  patients  in  the 
Polyclinic,  shows  in  the  former  a  greater  frequency  of  tuber- 
culosis in  the  families  than  in  the  latter,  but  it  is  more  marked 
in  the  side  branches  in  the  brothers  and  sisters  and  in  the  uncles 
and  aunts  than  in  the  direct  line  of  ascent,  therefore  says  more 
for  infection  than  for  heredity. 

In  Reiche's  i  ,H^t,  cases  between  the  ages  of  15  to  50,  29^7  per 
ceni.  males  suffering  from  phthisis  and  44*4  per  cent,  females  were 
descended  from  tuberculous  parents;  Avhereas  in  persons  without 
pulmonary  luberculosis  there  were  i2"8  per  cent,  males  and 
I7"6  per  cent,  females. 


iii';i<i<;i)n  Y  157 

Reiclic  coiisidtircd  ii  an  adv.-inla^c  in  su'  li  (|ii'-si  ir mis  lo  select 
older  persons  liecause  llic  nlinnaic  siaic  ot  ili<-  parcnis  is  better 
known.  I  look'  npon  Hiis  as  a  L;rcai  sonr(c  nl  ci  ioi-,  bccausf  in 
this  case  all  lliosc  parents  who  had  hccn  inlecled  long  after  the 
birth  an;  included  as  passin<^  on  ilicii-  disease,  which  is  clearly 
inadmissible. 

The  invesligalions  anion<4  groups  ol  people  li\in^  in  l<.r;ilii  if-s 
cut  off  from  communication  wiili  odicrs  are  valuable. 

Boeg,  who  studied  the  (jtiesiion  in  Hie  distant  I'arfW-  Islands, 
found  no  evidence  of  heredity,  bul  much  of  infection,  as,  on 
account  of  the  cramped  dwelling  accommodation,  even  men- 
servants  and  maid-servants  in  tuberculous  families  became  tuber- 
culous, and  were  thus  drawn  into  the  apparent  sphere  of  heredit}-. 
Similar  investigations  of  Fischer's  in  two  villages  in  the  Pdack 
Fore.st  in  Baden  gave  like  results,  namely,  that  tuberculosis  is  not 
a  disease  running  in  the  different  branches  of  one  famil}-,  but  of 
single  households. 

Johnson,  Kristen,  Storen,  Kluge,  Dbrner,  and  others,  arrived 
at  the  same  result,  namely,  that  tendency,  to  which  formerly  exces- 
sive consideration  was  given,  now  falls  into  the  background.  The 
fact  may  frequently  be  conlirmed  that  a  person  suffering  from 
phthisis  is  the  source  of  infection,  and  further  cases  group  them- 
selves about  him  v.hether  there  is  any  famil}'  relationship  or  not. 

We  know  further  from  countless  examples,  but  more 
especially  from  experience,  that  most  of  those  descended  from 
tuberculous  parents  when  they  are  separated  from  them,  and  are 
protected  from  the  ordinary  opportunities  of  infection,  remain 
healthy  in  spite  of  all  hereditary  tendencies  (Epstein,  Hutinel,  and 
Bernstein).  Peer  also  experienced  in  Heidelberg  that  hereditary 
tendency  was  unimportant,  that  new-born  babes  of  phthisical 
mothers  remained  health}'  when  given  to  healthy  wet  nurses. 

Thus  statistics,  in  as  far  as  they  satisfy  scientific  demands, 
and  are  not  simply  based  upon  an  uncritical  stringing  together  of 
figures,  giye  no  conclusive  support  to  the  acceptance  of  hereditary 
tendency  having  much  influence.  Clinical  experience,  when  it 
does  not  rely  on  figures,  is  too  dependent  on  personal  opinion,  and 
therefore  is  of  little  weight  (see  above,  Lugol  and  White). 

Therefore,  only  special  inyestigations,  such  as  those  carried 
out  by  Boeg  and  Fischer,  and  others,  which  really  express  clinical 
experience  in  an  exact  manner  can  be  taken  into  account,  and  this 
experience  teaches  us,  as  a  rule,  that  apparent  heredity  is  to  be 
taken  in  the  sense  of  contagion. 

Single  observations  are  just  as  little  determinative,  because 
in  them  chance  and  conditions  which  we  cannot  grasp  turn  the 
scale;  for  example,  according  to  Schonborn,   in  a  familv  where 


I^S  SCROFL  LOSIS 

ilie  taiher  was  lubcrculous  eiglu  children  dit-d  oi  luherculosis  ;  of 
live  fosier  tliildn-n  li\ing  in  the  same  house  only  one  died, 
apparenilv  a  striking  case  of  hereditary  affection;  but  in  another 
family  all  the  children  were  affected  with  tuberculosis  excepting 
the  son,  who  grew  up  with  lu-alihy  relaiinns.  There  are  hundreds 
and  thousands  of  siuh  cases. 

lAigol  considers  a  difference  in  the  age  of  the  parents  as  a 
cause  of  hercdiiv  has  been  proved  because  he  treated  many 
scrofulous  patients  in  whom  he  found  no  other  cause.  Who 
would  acknowledge  such  a  proof  of  heredity  a  tout  prix?  Yet 
there  are  authors  even  in  most  recent  times  who,  out  of  reverence 
for  their  origin,  echo  all  these  reasons  without  even  making  an 
attempt  at  independent  argument. 

Pegurier,  who  has  recently  investigated  the  tjuestion  of  the 
influence  of  inequality  of  age  in  marriages  which  have  taken  place 
too  early  or  too  late  as  affecting  the  susceptibility  to  tuberculosis 
in  300  families,  could  get  no  positive  proof  of  it. 

Tuberculosis  and  scrofulosis  and  the  other  factors  above- 
mentioned  are  too  widely  dispersed,  and  life  too  diversified,  and 
so  \arious  are  the  consequences  of  this  that  we  could  find  examples 
for  anv  theory  even  the  most  arbilrar^•.'  I^^'om  tliis  it  is  (|uite 
explicable  that  now  and  again  se\"eral  children  of  the  same 
family  are  attacked  by  the  same  form  of  scrofulosis,  such  as 
coxitis,  or  spina  ^■entosa,  an  occurrence  which  is  then  empha- 
sized as  remarkable.  Dent,  for  example,  treated  a  girl  aged  19 
w'ho  had  lupus  in  the  leg,  and  her  two  sisters  (who  had  alwriys 
slept  wdth  her)  had  lupus  also.  Very  often  certain  customs  or  bad 
habits  peculiar  to  a  family  may  lead  to  an  infection  of  the  same 
organ  ;  for  example,  picking  the  nose  might  lead  to  the  affection 
of  several  children  with  the  same  disease  of  the  nose.  Besides, 
such  analogous  affection  in  several  families  is  by  no  means  the 
rule ;  much  more  frequently  one  child  will  suffer  from  neck  glands, 
another  from  tuberculosis  of  the  bones,  and  a  third  from  phthisis. 

The  mistaking  in  former  times  of  syphilis  for  scrofulosis, 
from  the  retarded  form  of  wdiich  severe  scrofulosis  is  hardly  to  be 
distinguished,  may  have  had  much  to  do  with  the  view  of  the 
excessive  importance  of  heredity.  The  frequency  emphasized  bv 
earlier  authors  (including  Lugol)  of  stillbirths  and  abortions  in 
scrofulous  families  points  to  this. 

The  experience  of  Volkmann  that  fungous  inflammati(;n  of 
the  joints,  caries,  tuberculous  swelling  of  the  lymph  glands,  &c.. 


A  short  time  ago  a  notice  appeared  in  the  papers  that  three  members 
of  one  and  the  same  family  had  been  run  over  after   long  intervals. 


iii'.Ki-.ni  1  V  lyj 

are  noL  generally  tound  in  licallliy  families  agrees  very  well 
with  the  l.li(M)ry  oi  inteclion;  lor  in  such  affections  we  have  to 
do  lor  I  Ik;  greater  pari  with  a  class  rf^presented  by  young 
persons,  or,  at  least,  with  such  vvJKjse  maladies  had  already 
begun  in  childhood,  although  perhaps  in  another  situation,  and 
in  childi'cn  living  among  a  number  of  [persons  with  whom  they 
are  crowded  together,  and  who  are  thus  subjected  lo  tuber- 
culous infection  ;  we  have  to  do  with  a  disease  which  is  repre- 
sented in  the  parents  and  nearest  rei;ii ions  ("  pseudo-heredity  "). 
For  the  same  reason,  especially  in  children,  physicians  meet  with 
such  supposed  heredity  at  every  turn,  if  they  do  not  take  into 
considerati(jn  tlie  opportunities  for  infection  and  gi\e  them  their 
due. 

On  account  of  the  long  period  of  incubation  of  tuberculosis, 
it  may  happen  that  the  parent,  after  several  years  of  illness,  only 
gives  rise  to  infection  in  the  last  few  weeks  whilst  conlined  to  bed  ; 
tuberculosis  of  the  bronchial  glands  develops  extremely  slowly  in 
a  child  (even  with  the  small  animals  used  in  <nir  experiments  an 
inoculation  of  a  small  cjuantity  of  material  is  hardly  perceptible 
eight  weeks  later).  After  six  months  to  a  year  one  or  other  bacillus 
reaches  a  joint,  and  weeks  and  months  go  by  before  any  changes 
worth  mentioning  appear;  thus  between  the  death  of  the  parent, 
and  the  clinical  symptoms  of  the  child,  a  long  period  often  elapses. 

Latham,  who  in  his  collection  of  reports  points  to  the  entirely 
insufficient  grounds  for  the  acceptation  of  hereditary  tendency, 
admits  rather  a  gradual  increase  of  resistance  to  tuberculosis,  for, 
as  he  thinks,  almost  every  adult  is  somewhat  tuberculous  ( ?),  and 
therefore  most  of  our  forefathers  must  have  been  tuberculous,  yet 
turberculosis  is  decreasing  instead  of  increasing. 

Neither  the-  older  nor  the  newer  writings  on  the  subject  have 
as  yet  supplied  any  positive  proof  of  the  great  influence  of  heredity, 
exclusive  of  contagion. 

As  the  case  stands,  numerous  authors  arrive  at  a  more  or  less 
complete  repudiation  of  hereditary  predisposition  (Comby,  Piettre. 
Pariente,  Crouzon  and  \"illaret,  v.  Behring,  Calmeite ;  see  also 
Hazen's  investigations). 

On  the  whole  doctors  are  for  the  most  part  convinced  that  the 
heredity  of  tuberculosis  practically  plavs  a  verv  unimportant  part, 
a  fact  which  I  record  with  some  satisfaction  after  my  twentv  vears' 
struggle  with  the  theory  of  heredity  in  its  all-prevailing  forms,  a 
struggle  which  at  first  brought  me  general  opposition. 

Individual  variations  in  the  susceptibility  to  tuberculosis 
within  certain  bounds  have  never  been  denied.  But  the  opinion 
that   certain  individuals,    on   account  of   the   slightness   of   their 


l6o  SCROFULOSIS 

herediiar\'  tendencx ,  eiijo\-  alnn)si  certain  protection  troni  tuber- 
culosis has  been  contestetl ;  that  the  greater  or  less  predisposition 
alone  turns  the  scale,  and  that  the  exogenous  cause,  the  bacillus, 
is  c()mparati\ely  unimportant,  is  a  point  of  view  which  is  as  much 
unproven  as  it  is  to  be  repudiated  for  practical,  hygienic,  and 
prophylactic  reasons.  Schliiter,  in  his  excellent  work  written, 
under  the  a^gis  of  Mars,  comes  to  the  conclusion  that  there  is  no 
specific  tendency  to  tuberculosis  "as  an  inherited  or  acquired 
condition  which  can  be  consistently  defined,  and  which  exhausts 
itself  in  a  definite  anatomical  or  physico-chemical  quality." 

One  of  the  few  who  hold  a  fixed  idea  as  to  the  general  pre- 
disposition is  A.  Robin,  who  propounds  the  theory  of  deminerali- 
zaiit)n  (see  p.  52).  Sobotla  suspects  poverty  of  lime  also  in  a 
predisposed  person. 

As  far  as  a  general  special  predisposition  of  the  body  to  tuber- 
culosis and  tuberculo-scrofulosis  is  concerned,  we  may  expect  to 
gain  exact  knowledge  less  from  chemical  studies  than  from  further 
researches  in  bacteriology  and  immunity,  for  probably  the  higher 
or  lesser  degree  of  susceptibility  depends  on  deviations  in  the 
formation  of  protective  material. 

As  a  sort  of  hereditary  predisposition  it  is  conceivable,  though 
not  vet  proved,  that  on  account  of  bacterial  toxins  in  the  blood 
of  a  highly  tuberculous  father,  the  semen  becomes  changed, 
and  it  is  still  more  possible  that  the  toxins  of  a  tuberculous  mother 
pass  on  to  the  foetus  by  endosmosis.  In  practice  this  occurrence 
does  not  play  an  important  part,  for  parents  who  are  highly  tuber- 
culous only  rarely  beget  children  or  carry  the  ovum  the  full  time, 
and  because  such  embryos  soon  die  either  in  utero  on  account  of 
the  quantity  of  bacterial  toxin  or  extra  utero  from  debility  and 
atrophy,  as  we  have  observed  experimentally  in  animals.  But 
now  and  again  a  small  quantity  of  such  poison  may,  by  transuda- 
tion, induce  over  susceptibility  to  tuberculous  poison  w^hich 
we  can  bring  about  experimentally,  and  which  with  a  further 
supply  of  tubercular  toxin  by  infection  might  perhaps  have  a 
further  influence  on  the  course  of  the  disease. 

This  theory  is  approved  by  Soltmann,  but  this  author  pro- 
nounces scrofulosis  to  be  a  non-bacillary  toxic  tuberculosis  depend- 
ing on  pathological  chemotaxis  (see  p.  59). 

The  question  of  local  readiness  for  pulmonary  tuberculosis  on 
account  of  the  shortening  of  the  cartilage  of  the  first  rib  mentioned 
bv  Freund-Hart,  or  of  the  paralytic  thorax  according  to  Stiller,  lies 
outside  our  subject, 

I  will  only  mention  that  Danges  studied  the  possibility  of 
inheriting  the  so-called  phthisical  habit  in  194  phthisical  patients,. 


IIKRI.IJII  Y  lOl 

and  comes  Lu  tlic  conclusion  LliaL  lulicrilancc  oi  Liie  habitus  is  ju.-^l 
as  often  exemplilied  as  it  is  questionable  from  convincing  counter- 
proofs. 

Transmission  of  the  Tendency  to  Sorofulosis.  We  have 
hitherto  spoken  of  tuberculosis,  or  the  tuberculous  form  of  scrofii- 
losis.  The  transmission  of  hereditary  predispcjsition  to  the  true 
scrofulous  character  of  the  disease  lacks  convincing  statistical  or 
clinical  proof.  If  one  be  dif^cult  to  bring  forward  for  tuberculosis, 
a  further  difliculty  presents  itself  in  the  case  of  scrofulosis,  for  the 
family  history  of  the  former  scrofulosis  of  the  parents  can  only  be 
accepted  with  the  most  extreme  caution,  and  very  often  a  simple 
swelling  of  the  glands,  a  simple  rash  or  enlarged  tonsils  are  mis- 
tiiken  for  scrofulosis. 

On  the  other  hand,  it  cannot  be  denied,  even  if  the  disease 
itself  cannot  be  inherited,  yet  certain  anatomical  peculiarities  in 
the  skin  and  lymph  vessels,  which  we  are  inclined  to  call  a 
scrofulous  tendency,  may  be  inherited,  just  as  a  large  mouth, 
large  eyes,  &c.,  can  be  transmitted  from  parents  to  children. 

We  have  no  certain  data  as  yet  whether  this  scrofulous 
tendency  is  connected  with  a  certain  bodily  weakness,  or  whether 
it  appears  quite  independently  of  it,  whether  it  depends  on  some 
physical  inferiority  in  the  parents,  or  if  specific  disease,  such  as 
tuberculosis,  is  specially  adapted  for  the  procreation  of  children 
with  such  predisposition ;  the  often  repeated  statement  of  a  causa- 
tive connection  between  scrofulosis  and  stoppage  of  growth, 
arrested  development,  as  well  as  the  high  mortality  amongst  the 
children  of  a  family  needs  further  proof,  unless  infection  plays  a 
part. 

Only  by  extensive  comparative  statistical  and  anatomical 
studies  can  a  firm  foundation  be  laid.  It  is  not  enough  to  confirm 
a  more  or  less  frequent  number  of  cases  of  scrofulosis  in  a  numer- 
ous line  of  forefathers;  at  the  same  time  proof  must  be  brought 
that  the  same  factor  does  not  present  itself  in  a  like  number  of 
non-scrofulous  individuals ;  it  must  appear  less  seldom  or  not 
at  all. 

Ponfick  referred  his  scrofulous  diathesis  with  increased 
tendency  to  exudative  and  proliferative  reaction  to  an  inherited 
want  in  the  morphology  and  chemical  composition  of  the  organism 
of  a  child.  Czerny  claims  for  his  exudative  diathesis  "  a  con- 
genital defect  in  the  chemical  processes  of  the  bodv."  A  decided 
heredity,  especially  on  the  mother's  side,  but  which  is  difficult  to 
confirm  in  the  case  of  the  parents  at  the  time  of  their  vouth,  he 
considers  the  diathesis  not  as  a  special  sign  of  bodilv  inferioritv 
in    the    parents    (syphilis    and   tuberculosis),    for    in    children    of 

II 


102  SCROFULOSIS 

luberculous  parents  lliey  are  not  more  frequent  than  in  oiher 
children,  though  they  appear  with  special  frequency  in  the 
children  of  neuropathic  and  psychopathic  parents. 

The  findings  of  ]\Ioro  and  Kolbo  are  brought  forward  in  the 
sense  of  hereditary  influence.  According  to  them  the  signs  of 
exudative  diathesis  show  a  grouping  in  families,  and  it  appears 
six  times  as  frequently  in  the  brothers  and  sisters  of  children 
suffering  from  eczema  as  in  those  of  control  children.  The 
appearance  of  exudative  symptoms,  lichen  urticatus,  eczema,  &c., 
in  the  first  year  of  life  in  four-fifths  of  cases,  emphasized  especially 
by  Moro,  confirms  this.  Escherich,  on  the  contrary,  considers 
the  acceptance  of  a  congenital  scrofulous  condition  to  be  in- 
admissible, because  the  scrofulous  symptoms  only  appear  towards 
the  end  of  the  first  year,  and  then  there  is  already  a  positive 
reaction  to  tuberculin,  and  allergie  exists.  Preisich  also  contests 
the  direct  heredity  of  scrofulosis  (see  his  work). 


CHAPTER   VI. 

FACTORS  WHICH  FAVOUR  INFECTION. 


The  development  and  spread  of  scrofulosis  is  influenced  by 
a  series  of  external  factors.  Many  authors  vied  with  each  other 
in  bringing  forward,  with  a  certain  amount  of  sophistry,  new 
favouring  factors;  in  doing  this,  critical  research  was  sacrificed 
to  a  semblance  of  thoroughness.  For  what  is  the  good  of  bring- 
ing together  all  sorts  of  factors  which  appear  adapted  to  destroy 
the  health  of  man  without  a  shadow  of  proof  as  to  their  near 
connection  with  scrofulosis  ? 

Even  the  frequent  occurrence^  of  a  fact  does  not  become  an 
argument ;  for  example,  bad,  small  dwelling-houses  do  much  for 
the  dissemination  of  scrofulosis;  such  dwelling-houses  are  the 
natural  consequence  of  small  means  and  a  low  social  position. 
Therefore,  all  other  factors  which  are  invariably  connected  with 
this  low  social  position,  unhygienic  conditions,  insufficient 
nourishment,  overwork,  scanty  clothing,  perhaps  also  too  little 
sleep, ^  are  more  to  be  found  amongst  these  scrofulous  persons 
than  among  others,  without  it  being  admissible  to  take  each 
separate  factor  as  a  favouring  agent. 

Social  Position. — Social  position  takes  the  first  place  amongst 
the  influences  promoting  the  disease.  It  is  true  scrofulosis 
appears  in  all  classes,  amongst  high  and  low,  rich  and  poor,  still 
it  is  agreed  by  all  authors  that  it  is  found  infinitely  more  frequentlv 
amongst  the  poorer  classes  than  amongst  the  well-to-do.  The 
worse  the  outward  conditions,  so  much  the  more  plentiful,  as  a 
rule,    are    the    opportunities    of    infection    of    ever^    kind.     The 

'  Here,  as  with  heredity,  the  logical  aud  statistical  fundamental  rule 
is  broken,  that  it  is  not  enough  for  such  proof  to  confirm  the  frequent 
occurrence  in  scrofulosis  of  a  fact.  It  must  at  the  same  time  be  proved 
that  amongst  the  same  number  of  non-scrofulous  persons  the  same  fact  is 
observed  much  more  rarel5^ 

-  Poor  children  have  often  to  be  out  hawking  at  night,  and  in  the 
morning  to  be  up  early  to  deliver  newspapers,  hot  rolls,  &c. 


164  SCROFULOSIS 

localizaiion  oi  ihe  disease  seems  also  to  vary  somewliai  with  the 
social  position.  In  grouping  the  observation  of  Kanzler  on  this 
head,  we  lind  among  100  children  of  the  rich  40  per  cent,  with 
enlarged  cervical  and  occipital  glands;  of  100  children  of  the  poor 
we  have  70  per  cent,  with  local  affections,  accompanied  by  eczema 
on  the  head  and  face. 

Bad  housing  conditions  come  most  into  consideration.  But 
we  do  not  find,  as  was  thought  formerly,  that  the  principal  mis- 
chief is  in  the  chemical  condition  of  the  vitiated  atmosphere,  but 
in  the  quantity  of  germs  it  contains.  The  closer  and  more  crowded 
the  housing  conditions,  the  more  easily  do  dirt  and  micro- 
organisms of  all  sorts  accumulate,  the  more  often  can  the  bacteria 
enter  the  body,  deposit  themselves  on  the  tender  skin  of  the  child, 
and  cause  either  transitory  local  irritation  or  scrofulous  processes. 
The  greater  the  population  the  more  likely  are  we  to  find  tuber- 
culous persons  amongst  them,  and  their  dissemination  of  bacilli 
has  the  sad  consequence  of  tuberculous  scrofulosis. 

Dark  rooms  in  which  the  sun  scarcely  ever  enters  are  noted  as 
breeding  places  of  scrofulosis.  Long  experience  has  taught  us 
that  the  inhabitants  of  small  dismal  streets,  in  houses  which  look 
on  narrow  courts  surrounded  by  high  walls,  suffer  from  scrofulosis 
with  excessive  frequency ;  in  streets  that  are  equally  populous  on 
both  sides,  it  is  noticed  that  the  shady  side  will  have  more  cases 
than  the  sunny  side. 

Bacteriologically,  this  is  reasonable,  for  the  sun  is  an  incom- 
parable disinfector  which  can  destroy  even  the  highl}-  resistant 
tubercle  bacilli  in  a  few  minutes,  or  perhaps  hours,  in  its  direct 
rays,  and  in  a  few  days  in  dispersed  light,  and  it  acts  in  the  same 
way  on  those  light-shunning  germs,  the  other  pathogenic  bacteria. 

Besides  this,  want  of  sunlight  has  a  bad  influence  on  oilier 
bodily  functions,  the  formation  of  blood  decreases,  oxidation  is 
faulty,  and  the  powers  of  resistance  may  be  lowered.  We  cannot 
at  present  estimate  how  far  these  factors,  which  are  partly  founded 
on  theory,  come  into  consideration  in  the  production  of  scrofulosis. 

Damp,  musty  cellar  dwellings  are  rightly  considered  a 
developing  ground  for  scrofulosis,  as  humidity  of  itself  preserves 
bacteria  longer  than  dry  air.  Besides,  damp  dwellings  are,  as  a 
rule,  dark,  for  rooms  are  quickly  dried  in  the  light,  a  second  reason 
for  the  longer  existence  of  bacteria. 

In  drv  dwellings  the  bacilli  are  more  easily  dispersed,  and  are 
inhaled  in  greater  quantities  in  childhood,  inducing  pulmonary 
tuberculosis,  which  runs  a  speedy  course.  In  damp  air  (see  my 
experiments)  the  fine  pulverization  becomes  more  difficull,  and  the 
danger  of  tuberculosis  by  inhalation  is  lessened,  perhaps  avoided. 


FACTORS     VVIIK.II     FAVOUR     INFIX  I  ION  1 65 

Thus    in    damp   dwellings    InUtciion    by    coniai  i    may    (,<)iii<;    iiiL<j 
prominence  as  a  source  of  scrofulosis  which  runs  a  long  course. 

The  lli(;()ry  often  propounded  that  dainj),  dark  dwellings 
favour  the  growth  and  proliferation  of  th(;  tubercle  bacillus  outside 
the  body  is  in  contradiction  to  the  biological  laws  of  this  bacillus, 
which  requires  a  high  temperature  and  special  nourishment  to 
thrive  outside  the  body.  A  damp  and  dark  environment  as  a 
favouring  medium  for  growth  may  be  conceded  to  the  pyogenous 
bacteria. 

The  same  may  be  said  of  damp,  dark  workshops,  only  in  the 
case  of  adults  the  danger  of  scrofulosis  is  less  (see  above). 

The  old  prisons  and  dungeons,  damp,  dark  places  in  which 
cleanliness  was  looked  upon  as  a  luxury,  have  been  rightly  men- 
tioned as  breeding  grounds  for  scrofulosis  (prison  scrofulosis); 
while  scrofulosis  may  be  introduced  into  our  modern  light  and  airy 
prisons  and  reformatories,  noted  for  their  great  cleanliness,  it  may 
be  considered  to  have  disappeared  as  a  disease  engendered  in 
prison. 

The  same  may  be  said  of  prisons  as  has  been  said  of  dwell- 
ings, namely,  that  infection  by  contagion  is  evident. 

The  harmfulness  of  such  places  has  a  better  foundation 
bacteriologically  than  the  far-fetched  notion  of  Kanzler  and 
Mordhorst,  that  in  their  vitiated  atmosphere  respiration  becomes 
superficial  through  imperfect  aeration  of  the  venous  blood,  by 
which  engorgement  of  veins  arises,  followed  by  engorgement  of 
the  thoracic  duct  and  lymph-stream.  Overheating  and  enervation, 
which  have  been  put  down  to  living  in  such  places,  is  of  a  more 
problematical  nature. 

Uncleanliness  is  highly  conducive  to  the  production  of  scrofu- 
losis ;  uncleanliness  in  dwellings,  because  it  accumulates  germs  and 
multiplies  the  opportunities  of  infection  ;  want  of  care  of  the  skin, 
because  it  favours  contact  of  the  exterior  covering  with  bacteria, 
and  their  detention  ;  dirty  underlinen  easily  becomes  a  culture 
ground  for  bacteria,  bites  from  vermin  and  scratching  afford  them 
entrance. 

Tn  southern  lands  the  lax  ideas  of  cleanliness  are  compensated 
for  by  the  more  intense  light  of  the  sun,  which  destrovs  the  germs 
at  once,  and  also  bv  the  population  living  more  in  the  open  air. 

We  have  gained  a  decided  impression  that  repeated  and 
emphatic  instruction  in  the  prophylaxis  of  tuberculosis  has  not 
been  without  fruit.  Ostermann,  in  testing  the  surface  of  floors  in 
ten  instances,  found  half  of  them  free  from  bacilli,  in  spite  of 
extreme  dirtiness  (see  also  Preisich  and  Schiitz,  Hillenberg). 

We  meet  with  decided  infection  bv  dirt  also  in  the  better 


l66  SCROFULOSIS 

classes,  and,  in  combination  with  it,  shocking  iincleanliness  of  the 
body  itself,  though  often  more  covered,  and  not  noticeable 
externally. 

On  the  whole,  however,  the  severe  forms  of  scrofulous  skin 
affections  seldom  appear  in  well-to-do  families,  in  spite  of  tuber- 
culous infection,  in  spite  of  "  lymphatic  constitution  "  and 
Czernv's  over-nourishment.  On  the  other  hand,  we  find  in  a  less 
noticeable  form  tuberculosis  affecting  the  glands,  though  with 
cleanliness  in  other  ways,  by  the  instrumentality  of  sputum  in- 
cautiously treated,  such  as  spitting  into  the  handkerchief,  kissing 
tuberculous  persons,  tuberculous  milk,  &c.  This  may  often  occur 
in  all  the  children  of  a  family. 

Insufficient,  and  especially  unvaried  nourishment,  which  may 
also  be  improper  and  faulty,  is  mentioned  as  a  favouring  agent  in 
scrofulosis. 

From  the  standpoint  of  infection,  children  nursed  at  the  breast 
of  a  healthy  mother  will  become  scrofulous  much  less  easily  than 
those  nourished  with  cow's  milk,  especially  milk  from  tuberculous 
cows,  or  shop  milk,  or  milk  turned  sour. 

Feeding  infants  with  pap,  especially  when  a  tuberculous 
mother  or  nurse  has  tasted  the  food  previously,  may  be  a  possible 
cause  of  infection.  Demme  has  published  such  a  case;  a  nurse 
with  lupus  of  the  nasal  septum  and  tuberculosis  of  the  antrum  of 
Highmore,  in  this  way  caused  isolated  intestinal  tuberculosis  in 
four  children  (Nothnagel,  vol.  xiv,  3,  p.  201).  Coarse  food 
mechanically  irritating  the  walls  of  the  intestine  may  perhaps 
facilitate  the  entry  of  the  bacilli  into  the  intestines,  into  the  mucous 
membranes,  and  mesenteric  glands.  Scrofulosis  may  often  be 
observed  in  children  who  are  fed  at  too  early  an  age  with 
farinaceous  foods,  coarse  bread  and  potatoes,  or  with  vegetables 
rich  in  amylaceous  properties  and  cellulose,  which  overload  the 
intestines  by  their  bulk.  It  remains  undecided  whether  other 
causes  are  present  which  have  nothing  to  do  with  infection. 

The  overfeeding  with  milk  and  eggs  mentioned  by  Czerny 
may  in  many  cases  keep  up  and  aggravate  the  production  of  tuber- 
culosis, especially  the  exudative  symptoms,  but  whether  it  has  any 
great  influence  on  purely  tuberculous  persons  (the  most  important 
form  of  scrofulosis)  requires  further  proof. 

According  to  many  authors,  want  of  exercise  favours  scrofu- 
losis, but  perhaps  remaining  in  close  rooms  which  accompanies 
this,  and  the  increased  opportunities  for  infection  consequent  upon 
it,  should  bear  the  principal  blame.  According  to  others,  over- 
work or  hard  bodily  labour  acts  unfavourably ;  others,  again, 
accuse  onanism. 


FACTORS     WIIUH     lAVOCR     INMXJ'IION  1 0/ 

Pr(!gnan(:y  is  said  lo  iiinuciico  Uie  pr<jdLicli(jn  and  course  of 
scrofulosis.  Formerly  llie  legend  was  prevalent  that  scrofulosis 
was  caused  by  pregnancy  during  menstrual i(;n.  Jvehert  very 
appropriately  calls  such  causes  "  etiological  windmills." 

In  any  case  we  must  be  careful  not  to  over-estimate  these  and 
similar  factors.  Thus  Virchow,  for  example,  expressly  emphasizes 
ihat  when  hunger  typhus  raged  in  Upper  Silesia,  "  in  spite  of 
living  on  potatoes  and  in  bad  dwelling-houses,  scrofulosis  and 
tuberculosis  were  very  rare."  J>ugol  informs  us  that  neither  the 
besieging  army,  who  were  for  a  long  period  exposed  to  damp,  all 
sorts  of  privations,  most  unwholesome  food,  famine,  constant 
exertion  by  day  and  nigiit,  discouragements,  &c.,  nor  the 
besieged,  whose  fate  was  still  worse,  had  many  cases  of  scrofu- 
losis, though  they  suffered  from  scurvy  and  dysentery. 

Concerning  the  spread  of  scrofulosis  in  towns  and  in  the 
country,  many  authors  confirm  a  decided  difference  in  favour  o*" 
the  population  of  the  country.  The  fact  that  country  people  suffer 
less  from  scrofulosis  may  be  due  to  their  li\ing  more  in  the  open 
air,  and  so  incurring  less  risk  of  infection,  either  from  tubercle 
bacilli  or  pus  cocci ;  and  also  in  the  country  there  are  no  narrow 
streets  and  dark  courts.  These  advantages  are,  however,  in  many 
cases  counterbalanced  by  the  close,  unventilated,  small-windowed 
rooms  of  country  cottages  in  which  the  people  live  day  and  night 
during  the  long  winter  months.  In  many  cases  there  ,is  barelv  a 
division  between  the  living  rooms  and  cowsheds  and  stables,  so 
that  man  and  beast  live  amicably  together;  human  and  animal 
secretions  are  carelessly  heaped  up  together  in  the  country.  Local 
conditions  and  customs  are  too  various  to  set  up  a  general  rule, 
therefore  authors  making  observations  in  narrow  circuits  arrive 
at  results  contradicting  one  another.  Scrofulosis  has  even  been 
described  as  a  peasants'  disease,  and  been  put  down  to  a  too  large 
consumption  of  milk  and  butter. 

Lebert  and  others  find  no  difference  between  country  and 
towns. 

The  acknowledged  fayourable  influence  of  a  sojourn  in  the 
country  for  townspeople  can  naturally  lead  us  to  no  conclusions 
respecting  the  country  people  themselves,  as  the  two  liye  under 
entirely  different  conditions. 

Scrofulosis  appears  to  depend  little  on  climate  and  soil.  It 
has  been  stated  that  damp,  cold,  low-lving  places  are  much  more 
conducive  to  scrofulosis  than  dry,  warm,  highly-situated  districts; 
indeed,  formerly  low-lying  places  were  mentioned  as  a  direct  cause 
of  it;  but  older  authors  referred  to  the  contradiction  of  this  theory 
in  practice.     Thus  Lugol  pointed  out  the  frequency  of  scrofulosis 


l6S  SCROFULOSIS 

in  Spain  on  the  lable-land  of  Castile,  especially  in  Madrid,  while 
(on  the  other  hand)  it  is  often  little  met  Nvilh  in  the  dampest 
districts. 

Here,  as  in  tuberculosis,  we  must  in  the  first  place  take  into 
consideration  how  far  the  climate  tends  to  cause  the  population  ;o 
live  in  closed  rOoms  full  of  germs.  This  point  of  view  leads  us  to 
consider  that  seasons  must  also  exert  a  certain  influence;  winter 
would  afford  increased  opportunities  for  infection,  as  the  cold, 
cheerless  weather  would  lead  to  staying  indoors,  and  thus  infection 
would  declare  itself  after  weeks  or  months,  and  according  to  the 
energv  and  growth  of  the  germ  in  question  would  declare  itself 
by  a  local  or  glandular  affection.  In  fact,  some  authors  mention 
that  scrofulosis  affects  people  more  especially  in  the  spring,  that 
it  gets  worse  about  January  to  March,  and  then  decreases. 

Scrofulosis  is  undeniably  favoured  by  certain  illnesses, 
especially  the  acute  exanthemata;  in  fact,  they  appear  now  and 
again  to  induce  a  direct  outbreak  of  the  disease.  For  a  long 
period  measles  and  whooping-cough  have  had  a  bad  name  in  this 
respect,  and  after  an  epidemic  of  these  diseases  an  increase  of 
scrofulosis  has  often  been  observed  (Albrecht  and  others). 
Obstinate  spasmodic  cough  consequent  upon  swollen  bronchial 
glands,  and  the  pressure  on  the  nerves  induced  by  it,  has  been 
erroneously  mistaken  for  the  pertussis  which  leads  up  to  scrofu- 
losis. Scarlet  fever,  diphtheria  and  small-pox,  frequently  precede 
scrofulosis. 

In  a  case  of  Gougerot,  for  instance,  lupus  which  had  existed 
for  sixteen  years  increased  in  size  after  small-pox. 

The  epithelium  becomes  loosened,  and  the  continuity  of  the 
protective  covering  is  destroyed  by  the  catarrh  of  skin  and  mucous 
membranes  which  constantly  accompany  these  affections.  Bacteria 
adhere  then  more  easily,  and  thus  penetrate  and  deposit  them- 
selves. Such  infection  is  specially  favoured  when  children  live 
in  an  environment  full  of  germs,  especially  in  tuberculous  sur- 
roundings, and  when  the  sick-room  is  scrupulously  closed, 
darkened,  not  ventilated,  and  therefore  full  of  germs. 

In  a  great  number  of  cases  affections  of  the  glands  have 
existed  before  the  measles,  &c.,  occur,  especially  latent  (or  even 
manifest)  affections  of  the  bronchial  glands.  Such  have  been 
demonstrated  by  Loomis,  Pizzini,  G.  Cornet,  Spengler,  Harbitz, 
Weber  and  Baginsky,  Weichselbaum  and  Bartel,  Gaffky,  and 
others,  and  as  accidental  conditions  (see  Cornet,  "  Die  Tuber- 
culose,"  second  edition,  p.  370). 

The  usual  accompaniments  of  measles  and  other  exanthemata. 
— namely,    the  swelling  of  the  lymph   glands  already   infiltrated 


I'ACTOKS     WHICH     FAVOUR    INFECTION  l6y 

wilh  prc-exisLing  foci-  lonscn  .-iiid  inobili/.c  (lie  Ijacilli  and  incite 
new  growth;  the  glands,  liiilinio  laicni,  manifest  themselves  at 
this  time.  Mechanical  and  chemical  pnjcesses,  the  softening  of  the 
tissues  or  the  toxins  of  the  secondary  bacteria  (measles),  wash  a 
few  bacilli  out  of  the  gland.  vSevere  inflammation  can  even  cause 
the  tense  capsule  to  burst;  the  bacilli  thus  freed  disseminate  them- 
selves over  the  hilum  of  the  lung,  and  induce  the  exanthernatous 
phthisis  of  the  lungs — so-called  by  the  older  physicians.  Or  they 
enter  the  bones  and  joints,  or  cause  acute  miliary  tuberculosis,  or 
induce  in  the  skin  multiple  lupus,  multiple  tuberculosis,  tubercu- 
lides, or  scrofulides  (Adamson,  du  Castel,  Haushalter). 

It  is  often  difficult  to  decide  whether  we  have  to  do  with  a 
new  infection  or  a  manifestation  of  a  pre-existing  focus.  In  the 
tuberculous  form  multiple  and  rapid  appearance  points  to  the 
latter. 

The  dissemination  of  scrofulous  foci  and  metastases  appears 
to  be  greatly  facilitated  by  the  speedy  loss  of  flesh  resulting  from 
these  diseases,  also  by  faulty  nourishment,  for  reasons  explained 
before  (see  Cornet,  "  Die  Tuberculose,"  second  edition,  p.  682), 
by  the  increased  absorption  of  bacterial  poison  in  the  body, 
and  the  increased  difficulty  of  healing  consequent  upon  it  and  the 
easier  propagation. 

In  many  cases  slightly  virulent  bovine  bacilli  which  have 
entered  accidentally,  and  which  have  been  held  in  check  by  the 
power  of  resistance,  in  consequence  of  a  reduced  power  of  resist- 
ance as  a  result  of  measles  and  similar  affections,  may  develop 
and  disperse.  But  I  consider  it  unjustifiable  to  impute  consider- 
able vitality  to  such  latent  foci  of  bacilli  in  case  their  further 
development  is  hindered ;  at  least,  the  reasons  hitherto  brought 
forward  are  not  conclusive. 

I  consider  the  explanation  given  by  Henoch,  and  others,  of 
the  connection  between  scrofulosis  and  measles  unsatisfactory, 
namely,  that  where  a  tendency  to  scrofulosis  exists  it  will  suddenlv 
break  out  under  the  influence  of  these  acute  maladies. 

The  observation  has  been  often  made  bv  Happe  that  scrofu- 
lous children,  or  those  whose  parents  are  phthisical,  show  a  verv 
great  mortality  from  the  above-mentioned  diseases,  whilst  in 
children  of  healthy  families,  where  the  opportunity  for  infection 
is  lacking,  these  diseases  as  a  rule  pass  off  well,  and  it  is  only  in 
the  rarest  cases  that  tuberculosis  is  developed  from  them. 

Syphilis  is  accredited  with  a  prejudicial  influence  on  the  pro- 
duction and  course  of  scrofulosis  (this  is  contested  by  others).  (For 
vaccination  as  a  possible  promoting"  agent,  see  p.  14S.') 

Rickets,  struma,  cretinism  have  been  suspected,  without  due 
grounds,  to  be  favouring  agents. 


170  SCROFULOSIS 

Erysipelas  takes  a  special  place.  Sometimes  it  precedes 
scrofulosis,  and  mav  form  a  point  of  entry  for  the  partictdar  germ. 
But  in  other  cases  it  appears  during  the  course  of  scrofulosis,  and 
now  and  again  has  e\en  a  beneficial  influence  on  the  scrofulous 
processes  localized  in  ils  area  for  examplt',  lupus  (Berturelli, 
Winternitz,  Koliath,  Isnardi,  Ilallopeau);  this  \vas  also  known 
to  earlier  physicians,  for  instance,  Lugol,  and  reminds  us  of  the 
similar  temporarih-  favourable  effect  on  pulmonary  phthisis  (see 
Cornet,  "  Die  Tuberculose,"  second  edition,  p.  779). 

Tratmia  is  often  mentioned  as  a  further  accidental  cause  of 
scrofulosis.  Superflcial  injuries,  stings  of  insects,  and  bites  of 
vermin,  scratches,  burns,  and  chilblains,  so  frequent  in  scrofulosis, 
open  a  way  of  entrance  for  bacteria  and  tubercle  bacilli. 

Staphylococci  and  streptococci  especially  a\ail  themselves  of 
everv  injury  to  the  tissues  for  depositing  themselves,  and  easily 
induce  mixed  infection.  Germs  are  washed  away  from  larger 
wounds  by  the  bleeding. 

Awkwardness,  mischief,  play,  and  daring  cause  numerous 
wounds  during  childhood,  which  are  taken  little  notice  of,  and 
are  hidden  from  the  reproving  eyes  of  the  parents.  In  many 
parts  it  is  customary  to  bind  up  small  superficial  wounds  and 
contusions  with  rags  smeared  with  a  mixture  of  milk  and  cream, 
often  from  suspicious  sources,  or  to  smear  them  with  saliva  and 
blow  upon  them  ;  lupus  can  be  induced  in  this  manner.  Leloir 
informs  us  of  such  a  case.  Special  importance  is  attached  to 
coarse  forms  of  trauma  in  the  production  of  tuberculosis  of  the 
bones  and  fungous  joints.  We  can  onlv  refer  to  what  has 
already  been  said  of  tuberculosis,  especially  as  in  bones  and 
joints  we  have  only  to  do  with  the  tuberculous  form  of  scrofulosis. 

V.  Baumgarten  supposes  that  inherited  bacilli  find  in  the 
lymph  glands  and  marrow  a  suitable  nidus,  and  there  pass  their 
larval  existence  till  external  conditions  reduce  the  vitality  of  the 
tissues.  But  if  only  on  account  of  the  rarity  we  cannot  agree  with 
the  opinion  of  this  highly-esteemed  investigator.  Another 
hypothesis  is  that  the  bacilli  circulate  harmlessly  in  the  blood  of 
an  individual  suffering  from  scrofulosis  of  the  bones  caused  by 
trauma,  and  only  at  the  moment  and  in  the  place  "  where,  on 
account  of  trauma,  a  suitable  culture  ground  has  been  prepared 
for  them  "  do  they  deposit  themselves.  Now  as  a  rule  virulent 
bacilli  only  appear  in  the  blood  in  acute  miliary  tuberculosis,  rarelv 
in  phthisis,  to  say  nothing  of  the  blood  of  apparently  healthv 
persons,  therefore  the  conditio  sine  qua  non  is  wanting.  Surgical 
experience  declares  against  bacilli  circulating  in  the  blood,  a 
theory  which  has  recently  been  pushed  to  the  front,  for  we  know 


FACTOJiS     WHICH     JA\0(;)<     JMl-.CJIUN  171 

thai,  witli  scrofulous  .-md  plilliisic  .-il  jj(;rsons  a  wound  somfiirncs 
after  severe  trauma  and  cxlensive  laceratifjn  requiring  nifjntlis  to 
heal  never  becomes  tuberculous. 

In  my  opinion,  in  some  of  the  cases  of  bone  and  joint  scrotu- 
losis  which  are  associated  with  trauma  tliere  exists  somewhere, 
and,  as  pathological  experience  teaches,  most  frequently  in  the 
bronchial  glands,  a  latent  tuberculous  focus.  The  distended 
capsule  of  the  swollen  tuberculous  bronchial  glands  can,  either 
directly  or  by  cunlrecoup,^  which  is  often  Iransiniiled  from  a 
distance,  be  compressed  or  injured,  and  one  or  another  of  the 
biicilli  squeezed  out  by  the  sudden  shock  and  so  reach  the  lymph 
and  blood  systems.  At  the  exact  place  where  the  trauma  has  been 
effected,  where  the  path  of  the  vessels  is  disconnected  by  the  con- 
tusion, the  bacilli  will  be  interrupted  in  their  regular  course,  force 
themselves  into  the  tissues,  and  there  set  up  a  metastasis.  Accord- 
ing to  the  experiments  of  Schiiller,  the  bacteria  which  have  entered 
the  blood  appear  to  deposit  themselves  more  easily  in  a  contused 
joint  than  in  a  non-contused  joint.  But  we  come  across  certain 
difficulties  in  this  theory.  The  fact  that  such  affections  are  caused 
especially  by  sprains  and  dislocations  is  to  be  explained  by  the 
fact  that  in  greater  injuries  the  bacilli  are  washed  away  by  the 
haemorrhage. 

Our  theory  is  supported  by  the  proof  of  latent  tuberculous  foci 
as  already  mentioned,  the  presence  of  which,  even  in  considerable 
numbers,  must  necessarily  result  from  the  following  considera- 
tions :  In  Prussia,  for  instance,  over  17,000  young  persons  under 
20  years  of  age  die  yearly  of  scrofulosis  and  tuberculosis.  We 
must  suppose  if  only  a  three  or  four  months'  period  of  latency  for 
this  low  age  is  accepted,  there  are  about  4,000  or  6,000  persons  in 
Prussia  suffering  from  latent  tuberculosis. 

Blows,  falls,  and  contusions  are  such  everyday  occurrences 
in  youth  that  latent  foci  and  trauma  must  be  everlastingly  happen- 
ing together.  Such  coincidence  has  not  always  sad  consequences, 
for  how  often  does  trauma  happen  to  children  without  metastasis 
occurring,  in  spite  of  all  hereditary  affections,  and  in  spite  of 
manifest  tuberculosis  ?  Therefore,  great  reserve  is  necessary  in 
an  estimate  of  a  causative  connection. 

In  manv  cases  the  trauma  may  be  the  effect  and  not  the  cause  ; 
an  alreadv  existing  bone  and  joint  disease  in  its  initial  stages 
produces  no  svmptoms  whatever,  but  after  a  certain  time  it  inter- 
feres with  concerted  movement ;  generally,  at  first  unconsciously, 
it  makes  the  movements  uncertain,  and  on  this  account  leads  to  a 

^  Perhaps  tearing  of  the  knee-cap  may  be  caused  by  excessively  hasty 
movements,  in  a  fall  to  preserve  the  balance. 


^^~  SCROFULOSIS 


trann";'-,'"*",    ''    "'"'"'''l'    '""'"'    "'"    ^^^^   ^^-^^^    importance    of 
trauma,  and  supposes  that  a  bone  disease  was  already  existing 
and  the  external  influence  only  hastened  its  course,  while  in  othf; 
cases  any  traumatic  inBuence  may  be  excluded  with  certainty 

1  would  also  refer  to  the  recent  uorks  of  Friedrich    Honsell 
and^  S,,rengel.   who  place  the   inOucnce  of  trauma   on   f  mfn"'. 


SECTION   II. 

Morbid   Anatomy. 


In  considering  the  morbid  anatomy  of  scrofulosis  we  must 
separate  the  two  principal  forms,  the  pyogenic  and  the  tuberculo- 
scrofulous,  as  we  did  in  considering  tlie  etiology  of  the  disease. 

(1).     PYOGENIC  FORM. 

We  gather  from  former  statements  that  the  pyogenic  form 
carries  no  pathological  signs  in  itself  which  differentiate  it  in  any 
pathognomonic  sense  from  similar  affections  of  a  non-scrofulous 
nature. 

Scrofulous  catarrh  of  the  mucous  membrane  shows  exactly  the 
same  changes  as  ordinary  catarrh,  distension  of  the  vessels  and 
hyper^emia,  swelling  and  thickening  of  the  mucous  membrane, 
increased  mucous  secretion,  and  enlarged  mucous  glands, 
increased  casting  off  of  epithelium,  and  secretion  of  blood  serum 
mixed  with  corpuscular  elements  of  the  blood. 

Analogous  symptoms  are  met  w'ith  in  eczema,  in  catarrh  of 
the  skin,  whether  it  be  of  scrofulous  nature  or  not,  distension  of 
the  capillaries,  often  considerable  swelling  of  the  papillae,  increased 
shedding  of  thickened  epidermis,  transudation  of  blood  serum  and 
corpuscles,  infiltration  and  thickening  of  the  epidermis  and  corium. 

The  number  of  cells  in  the  secretions  mentioned  b}'  Rindfieisch 
as  characteristic  of  scrofulosis,  and  the  closer  cell  infiltration  of 
the  parenchyma  rich  in  connective  tissue,  to  which  Rabl  had 
before  referred  as  characteristic,  are  found  also  in  chronic  non- 
scrofulous  inflammations  as  noted  by  Birch-Hirschfeld.  The 
swollen  nose  and  upper  lip  are  not  specific,  but  occur  also  through 
congestion  in  other  layers.  The  long  duration  and  frequent 
invasion  of  germs  bring  the  toxic  principals  to  a  climax,  and 
induce  a  gradual  intensifying  of  the  svmptoms  till  the  formation 
of  ulcers  occurs. 

A  description  of  the  morbid  anatomy  of  the  skin  and  mucous 


174  SCROFULOSIS 

membranes  in  pyogenic  scrofulosis  woukl  be,  therefore,  only  .'t 
repetition  of  descriptions  of  simple  catarrh  of  the  skin  and  mucous 
nienibranes,  simple  conjunctivitis,  rhinitis,  adenoid  growths, 
bronchitis,  catarrh  of  the  intestines,  vaginal  catarrh,  &c.,  already 
given  in  other  portions  of  this  work.  The  peculiarity  of  the 
scrofulous  form  of  disease  consists  in  its  very  slow  course,  conse- 
quent upon  anatomical  conditions,  its  frequent  temporary 
concurrence  with  similar  affections  in  different  places,  its  multi- 
plicity and  frequent  recurrence. 

We  will  devote  a  few  words  to  the  lymph  glands  only,  on 
account  of  their  dominating  character  in  the  phases  of  the  disease. 
We  have  to  do  with  those  changes  which  were  formerly  called  the 
tirst,  or,  according  to  Virchow,  the  hyperplastic  stage. 

At  this  stage  we  rarely  see  scrofulous  glands,  because,  as  a 
rule,  they  rarely  need  surgical  treatment,  and  in  the  cadaver 
advanced  and  combined  processes  are  generally  the  objects  of 
investigation. 

At  first  the  gland  is  only  slightly  enlarged  up  to  perhaps  the 
size  of  a  walnut,  and  is  of  a  soft  elastic  fleshy  consistence,  the 
blood-vessels  are  injected,  more  especially  in  the  capsule,  and 
chiefly  when  the  acute  stage  is  investigated.  On  incision  the 
surface  is  fiat  and  regular,  marrow  like,  moist,  glossy,  and  slightly 
transparent,  of  a  blue-grey  colour,  but  sometimes  reddish  on 
account  of  hvper^emia,'  sometimes  whitish  owing  to  an  increase  of 
lymph  corpuscles. 

At  a  later  stage  the  surface  is  drier,  the  structure  of  the  tissue 
is  altered  and  more  homogeneous,  and  the  consistence  firmer 
owing  to  the  aggregation  of  cells.  Under  the  microscope  one  sees 
besides  a  great  distension  of  the  blood-vessels,  an  enormous 
increase  of  lymph  corpuscles,  especially  in  the  capsule.  There- 
fore the  scrofulous  gland  swelling  is  a  "  hyperplastic  lymphoma 
abounding  in  cells  "  (Virchow).  In  many  cases  the  inflammatory 
formation  of  connective  tissue  in  the  capsule  is  in  excess  of  the 
connective  tissue,  septa,  and  the  reticulum  (fibrinous  hyper- 
plasia induration). 

The  swelling  of  the  gland  may  continue  for  a  long  period 
in  this  condition.  If  it  has  not  continued  too  long  involution 
will  take  place,  as  the  hyperplasia  may  be  absorbed  and  disappear 
by  the  metamorphosis  of  fat  (scrofula  fugax),  and  only  the 
thickened  walls  of  the  capsule  and  the  denser  fibrous  septa  of 
connective  tissue,  forming  a  slight  enlargement  and  hardening 
of  the  gland,  remain  as  evidence  of  what  has  taken  place.  Pus 
foci  may  be  formed  if  the  addition  of  virulent  germs  exacerbates 
the  process ;  these  are  recognizable  on  the  incised  surface  as  yellow 


.MOl<i;il)   ANA'IO.MY  I  7.5 

spots  and  isolalcd  p.-ilclics  ;  il  ilif  f\lciil  is  sli^dil  llify  will  oficn 
involiilc,  lliickcn  and  calcify,  (icncivdiy  lli(;y  bh-nd  lo^fMlicr,  tlio 
inflainnialory  irritalion  extends  lo  ilu-  prTipliery  of  llif;  gland, 
forming  [)eriadenilis,  a  further  area  l)C( ouks  phlegmonous,  and 
after  (he  discharge  of  pus  ihe  wniiiid  (  i(  ai  ii/,<s. 

We  cannot  at  present  decide  whether  f<;ci  avc.  deposited  in 
bones  and  joints  from  non-tuberculous  scrofulous  glands,  or 
whether  the  scrofulous  bone  and  joint  affections  are,  without  excep- 
tion, of  tuberculous  nature  from  the  beginning.  The  probability 
of  the  former  theory  is  not  to  be  entirely  laid  aside,  but  in  sucli 
cases  the  characteristic  fungous  character  will  not  develop. 
According  to  the  knowledge  hitherto  obtained  of  the  histological 
structure  and  the  bacteriology  of  scrofulous  bone  and  fungous 
joints,  such  an  event  must  be  considered  quite  exceptional,  and  as 
a  rule  we  may  consider  bone  and  joint  scrofulosis  and  bone  and 
joint  tuberculosis  identical. 

(2.)     TUBERCULOUS  FORM. 

I  can  put  the  matter  concisely  as  regards  the  tuberculous  form. 
Its  chief  characteristic,  the  tubercle,  and  its  histological  nature 
and  development,  have  been  thoroughly  discussed  in  my  "  Tuber- 
culose,"  second  edition,  p.  59,  on  the  basis  of  the  masterly  works 
of  Virchow,  Schiippel,  and  v.  Baumgarten.  As  lupus  and 
scrofuloderma  have  been  described  anatomically  in  the  volume  on 
"  Diseases  of  the  Skin  "  (Nothnagel,  vol.  xxiv),  I  will  only 
mention  that  lupus  is  represented  histologicalh"  as  a  granulation 
tissue  with  typical  tubercular  nodules,  which  are  specially  distin- 
guished by  their  dearth  of  tubercle  bacilli  (possibly  on  account  of 
the  low  temperature  of  the  skin,  which  hinders  their  develop- 
ment) ;  the  nodules  may  disintegrate  and  be  absorbed ;  in  other 
cases  ulcers  form  (lupus  ex-ulcerans),  covered  with  a  thick, 
coloured  crust ;  in  others,  again,  there  is  diffuse  infihration  and 
hyperplasia  of  the  connective  tissues  between  the  nodules  which 
extend  over  the  skin  (lupus  hypertrophicans) ;  often  we  find  on  the 
lupus  nodules  reddish-brown,  scaly,  smooth  patches  (lupus 
maculosus),  which  give  way  under  the  pressure  of  the  probe 
(Neisser).  Besides  caseous  disintegration  and  absorption,  the 
nodules  can  undergo  a  fibrous  transformation. 

Scrofuloderma  is  a  subcutaneous  wartv  granulation  tissue 
with  tubercles  and  tubercle  bacilli ;  it  is  much  more  sharply 
defined.     Its  changes  are  discussed  on  p.  184. 

We  meet  with  several  types  of  tuberculous  Ivmphatic  glands. 
In  pure  tuberculosis  there  are  deposited  in  the  parenchyma  of  the 


176  SCROFULOSIS 

glands  more  or  less  numerous  tubercular  nodules;  ihe  inilam- 
matorv  irritation  and  the  redness  and  swelling  attendant  on  it  is 
slight.  The  development  of  tubercles  of  the  lymphatic  glands  is 
on  the  same  lines  as  that  already  described  at  the  above-mentioned 
place  in  the  inoculation  tubercle  of  the  iris,  and  the  differences  are 
only  in  degree;  inasmuch  as  "  the  proliferation  of  the  cells  is  more 
moderate  and  proceeds  more  slowly,  and  the  infiltration  pheno- 
mena are  more  insidious  and  less  numerous  "  (v.  Baumgarten). 
This  is  explained  by  the  fewer  number  of  germs  of  infection.  The 
glands  have  a  relatively  favourable  chance  of  resolution  after 
remaining  long  in  this  condition. 

In  other  cases  the  nodules  gradually  enlarge,  merge  into  each 
other  and  form  a  conglomerate  tubercle,  the  nodules  caseate  in  the 
centre,  the  caseous  matter  may  remain  enclosed  for  a  long  period, 
and  calcify  by  taking  up  lime  salts,  or  it  softens,  undergoes 
changes  from  periadenitis,  ruptures,  and  discharges. 

Apparently  in  this  case  the  tubercle  bacilli  soon  die  after 
caseation  has  set  in,  probably  owing  to  the  bacterial  poisons  which 
are  concentrated  and  retained  in  the  tubercles  of  the  lymph  glands ; 
bacilli  can  but  seldom  be  demonstrated  in  the  softened  caseous 
matter. 

In  the  changes  arising  from  bovine  infection,  Benda  noticed 
the  scarcity  of  giant  cells  and  the  quantity  of  tubercle  bacilli 
which,  as  we  know,  are  only  to  be  found  sparsely  in  human 
infection. 

The  whole  process  often  only  consists  of  a  building  up  of 
epithelioid,  spindle-shaped  cells  (with  few  bacilli),  which  suppress 
the  lymph  gland  tissue ;  caseation  is  absent  for  a  long  time,  and 
the  glands  remain  stationary  at  the  size  of  a  hen's  egg — large- 
celled  hyperplasia  (Ziegler). 

After  inoculating  tubercle  bacilli  into  animals  not  susceptible 
to  the  type  inoculated,  Bartel  found  swelling  of  the  follicles  and 
endothelium  and  lymphoid  hyperplasia,  and  designates  this  the 
lowest  grade  of  specific  change  of  tissue  of  a  tubercle  which  has 
been  arrested  in  development ;  similar  conditions  in  man  are 
etiologically  to  be  considered  as  caused  by  non-virulent  bacilli  in 
like  manner. 

On  the  other  hand,  caseation  and  softening  take  place  very 
quickly  when  in  the  further  course  a  different  kind  of  inflammatory 
process  (mixed  infection)  is  set  up.  In  these  cases,  which  are  not 
rare,  the  glands  which  for  a  long  time  have  remained  stationary 
with  little  enlargement  exhibit  more  or  less  acute  inflammation, 
swell  considerably,  and  break  through  in  so  short  a  time  that  the 
caseous  mass  mixed  with  pus,  whicli  is  then  thrown  off,  could  not 


MORIill)  ANATOMY  177 

p(j.s.sil)ly  have  ])('.(:n  foriixMl  in  so  sliori  a  liine,  anrl,  in<.\<-<--(\,  Iroiii 
its  appeamncc  indicates  a  hjnger  existence  than  the  incidental 
inflammation. 

In  other  very  frecjuent  cases  the  tubercle  develops  in  a  gland 
whicli  is  already  changed  by  cell  infiltration,  and  generally  con- 
siderably enlarged,  which  condition  we  have  already  described  as 
the  attribute  of  pyogenic  scrofulosis.  Dull,  greyish-white  points 
and  spots  appear,  whicli  enlarge  and  turn  t(;  whitish-yellow, 
opaque,  dry,  dotted  foci  in  the  grey  hyperplastic  gland  and  then 
gradually  coalesce ;  at  last  tlie  whole  gland  appears  to  be  a  homo- 
geneous caseous  mass,  which,  when  cut  in  two,  "  looks  like  a  new 
potato,  only  not  quite  so  moist  "  (Virchow). 

In  this  case,  too,  caseation  and  softening  take  place  speedily. 
Isolated  glands  are  absorbed  as  the  result  of  periadenitis;  we 
frequently  tind  extensive  cellulitis,  and  at  last  rupture  occurs  in 
one  or  several  places,  in  favourable  cases  externally  through  the 
skin,  but  now  and  again,  according  to  the  position  of  the  glands, 
into  the  bronchi,  the  larger  vessels,  pericardium  and  peritoneum  ; 
several  times  a  miliary  tuberculosis  development  has  been  seen 
also  in  the  surrounding  muscles. 

In  cases  of  mixed  infection,  no  matter  whether  the  tubercle 
bacillus  or  the  pyogenic  organism  has  established  itself  first,  the 
principal  danger  lies  in  the  two  processes,  which  would  easily 
make  a  dissemination  of  the  tubercle  bacilli  over  the  whole  bodv 
possible.  The  danger  appears  less  when  the  tubercle  bacillus 
alone  settles,  because  it  grows  much  more  slowly,  and,  as  experi- 
ence has  shown  us,  is  easily  encysted  in  the  glands  (see  p.  125). 
The  point  of  lesion  only  closes  when  all  caseous  material  is 
removed,  either  spontaneously  or  artificially,  generally  only  when 
the  gland  has  ceased  to  exist.     The  scar  is  usually  much  retracted. 

In  favourable  cases  the  caseous  mass  becomes  calcified  even 
at  this  stage,  and  is  closed  by  indurated  connective  tissue  either 
for  a  time  or  altogether. 

The  hyaline  masses  which  are  found  in  the  Ivmph  glands  are 
referred  to  by  Warthin  as  healed  tuberculous  foci. 

In  scrofulous,  or  more  properly  tuberculous,  bones  we  find 
in  the  marrow  grey  or  greyish-red  granulation  foci  in  which 
Koster  demonstrated  typical  tubercles,  and  more  recent  authors 
tubercle  bacilli.  These  granulations  or  fungus  growths  break 
down  the  lacunae  of  bone  tissue  around  them  (caries  sicca),  spread 
to  the  periphery,  and  caseate  from  the  centre. 

The  trabeculse  of  bone  within  the  caseous  mass  become 
necrotic  when  they  are  destroyed ;  they  form  bone  sand,  and  are 

12 


]-S  SCROFULOSIS 

the  more  numerous  ihe  quicker  the  caseation  extends;  with  rapid 
caseation  larger  pieces  of  bone  become  necrotic  and  covered  with 
granulations  which  have  caseated. 

Then  there  are  found  in  the  bones  several  spaces,  cloacae 
surrounded  bv  granulations,  containing  caseous  pus  in  which  are 
found  bone  sand  and  sequestra. 

Small  and  even  larger  foci  can,  especially  in  youth,  be  caused 
to  heal  by  reactive  granulating  ostitis.  \\'e  do  not  know  with 
certaintv  how  long  the  bacteria  can  retain  their  vitality  in  encysted 
foci,  and  therefore  how  long  before  they  can  resume  their  harmful 
activity  when  set  free  by  later  traumatic  influences  or  by  measles, 
scarlet  fever,  whooping-cough,  &c.,  but  their  length  of  life  is 
generally  over-estimated  (Cornet,  "Die  Tuberculose,"  second 
edition,  p.  375).  Larger  foci  also  attack  the  periosteum  and  the 
surrounding  soft  parts,  even  involving  the  joint. 

Proliferations  in  the  neighbourhood  of  the  tuberculous  focus 
are  followed  by  absorption  of  the  bone,  and  apposition  to  neigh- 
bouring parts.  Absorption  taking  place  within  the  bone,  and  at 
the  same  time  apposition  to  the  periosteum,  leads  to  the  apparent 
distension  of  the  bone  known  as  spina  ventosa,  which  takes  place, 
especially  on  the  phalanges  of  the  fingers,  toes,  and  the  ends  of 
the  long  bones,  for  example,  the  ulna.  If  the  apposition  is 
greater  than  the  absorption  the  bone  naturally  becomes  thickened. 

Tuberculous  periostitis  is  caused  by  the  extension  of  the  focus 
in  the  bone  to  the  periosteum,  but  also  in  the  primary  seat  of 
disease,  or  from  the  joint.  We  find  granulations  containing 
tubercle  bacilli  which  lead  to  the  absorption  of  the  adjacent  bone 
(peripheral  caries).  By  the  caseation  and  softening  of  these 
granulations  so-called  cold  abscesses  are  formed  ;  they  are  covered 
with  granulation  tissue  containing  tubercle  bacilli,  and  are  often 
very  large ;  owing  to  the  movements  of  the  muscles  they  are 
frequentlv  considerably  displaced  (wandering  abscesses).  Their 
inspissated  contents  consist  of  a  caseous  disentegrated  mass,  pus 
corpuscles,  and  pieces  of  necrotic  bone.  Generally  in  the  process 
spontaneous  rupture  takes  place  with  tedious  formation  of  fistul^e. 

The  especially  favoured  site  of  tuberculous  osteomyelitis  and 
periostitis  in  the  spongy  ends  of  the  bones  explains  the  frequent 
secondary  participation  of  the  neighbouring  joint;  these  may  also, 
but  in  very  rare  instances,  be  affected  primarilv.  Their  infection 
by  the  bones  takes  place  by  direct  ingrowth  of  the  tuberculous 
focus  or  bv  the  lymph  channels. 

Most  frequently  we  find  proliferations  of  the  synovial  mem- 
branes and  inflammatory  affections ;  less  often  single  detached 
tubercles  in  a  synovial  membrane  which  is  little  changed. 


MOKl'.ll)   ANATOMY  179 

Al  a  laicr  siagf  iikh-c  or  less  iiiiiu'-khis  iiibercles  and  greyisli- 
vcl low  caseous  loci  lia\c  toinu'd  m  ihr  synovia!  incnibranc,  which 
becomes  red  and  llii(  kcn<-<l,  :\\u\  is  .  hanged  into  a  sjjongy  granula- 
tion tissue  (I\()Slci).  1  he  joiiii  (avity  shows  an  exudate  at 
various  slagf-s,  eilhcr  sero-lihrinoiis  (hych-ops  nilx-rculosus)  or  of 
a  purulent  nature  (empyema  ariiculi  tubcii  uiosuni).  '1  Ik;  free 
bodies,  corpora  oryzoidea,  often  md  with,  consist  (A  detached 
lumi:)S  of  fibrin   from  the  syiio\  ial  nicmbranf. 

A  serous  or  sero-fibrinous  li\dr()i)s  of  the  joint  is  formed  by 
transudation  of  tulx'rcle  toxins  of  a  neighbouring  bone  focus,  llie 
same  as  occurs  in  (he  pleura  and  pericardium  from  a  tuberculous 
lung  or  bronchial  gland.  In  the  fibrinous  matter  thus  cast  off,  a 
development  of  tubercles  may  take  place  by  the  tubercle  bacilli 
which  enter  later,  InU  we  ma_\'  not  on  that  account  come  to  the 
conclusion  that  the  deposit  of  fibrous  material  arises  from  an 
entirely  different,  perhaps  pyogenic  infection,  and  that  the  tuber- 
culosis is  only  secondary  and  accidental,  as  Biedert  seems  to  have 
done.  The  absence  of  tubercle  in*  such  melon-seed  bodies  just  as 
little  contradicts  its  tuberculous  origin,  for  they  may,  as  well  as 
a  hydrops  of  the  joint,  be  a  product  of  the  toxin. 

If  the  fungous  state  has  entered  the  cartilage  we  find  it  eroded 
and  destroved,  and  Avhen  growths  are  present  in  the  subchondral 
tissue,  it  is  often  completely  raised  from  the  bone  and  detached 
from  it.  After  quick  disintegration  of  the  fungous  tissue  we  often 
meet  with  extensive  destruction  of  the  joint  (tuberculous  caries  of 
the  joint) ;  from  the  caseated  and  softened  granulations  the  above- 
mentioned  cold  abscesses  are  formed. 

The  soft  parts  around  the  joint  are  affected  at  the  same  time 
and  become  cedematous,  the  connective  tissue  dense  and  thickened, 
the  whole  joint  looks  waxy  and  shiny  (tumor  albus). 

The  more  exact  histological  condition  of  bones  and  joints, 
and  the  changes  which  take  place  in  the  various  regions  of  the 
bodv,  cannot  be  considered  here;  for  information  respecting  them 
1  refer  to  works  on  surgery  and  morbid  anatomy. 

T  will  here  just  mention  the  changes  similar  to  bovine  infec- 
tion which  are  found  now  and  again  in  the  further  extension  of 
the  tuberculo-scrofulous  processes. 

\^irchow  and  Askanazy  have  drawn  our  attention  to  their 
occurrence,  and  A.  Uffenheimer  found  bovine  characters  in  the 
affected  intestines  of  a  child ;  Ipsen  and  Maccallum  have  observed 
similar  cases. 

The  further  inoculation  in  a  calf  in  Ipsen 's  case  had  a  negative 
result. 


SECTION   III. 

Symptoms. 


The  symptoms  of  scrofulosis  show  certain  deviations  both  in 
their  local  and  general  character,  according  as  we  have  to  do  with 
the  tuberculous,  the  pyogenic,  or  the  mixed  form. 

As  a  rule,  in  infancy  it  is  especially  the  skin  and  primary 
symptoms  in  the  mucous  membranes  which  predominate,  then  the 
secondary  processes  in  the  mucous  membranes  follow,  and  lastly 
swelling  of  the  lymphatic  organs;  these  especially  predominate 
from  the  fourth  to  the  tenth  years. 

In  pyogenic  scrofulosis  the  local  phenomena  of  the  area  from 
which  it  arises  are  chiefly  in  evidence,  then  follows  swelling  of  the 
glands,  and  it  is  only  rarely  that  the  process  invades  the  bones. 
The  general  symptoms  are  less  marked  than  in  the  tuberculous 
form  on  account  of  the  less  toxic  qualities  of  the  bacteria. 

In  the  tuberculous  form,  for  reasons  which  have  been  given 
in  another  place,  the  symptoms  in  the  skin  and  mucous 
membranes  are  less  marked  than  the  changes  in  the  glands ; 
to  these,  bone  affections  are  added  later.  The  general  symptoms 
in  the  tuberculous  form  rarely  attack  so  deeply  or  are  so  acute 
as  in  tuberculosis  of  other  organs,  the  lungs  and  brain,  for 
instance.  As  has  already  been  pointed  out,  the  reason  for 
this  is  in  the  anatomical  conditions,  which  offer  certain 
hindrances  to  the  dispersal  and  proliferation  of  the  bacilli,  also 
the  skin  glands  and  bones  in  which  the  pathological  changes  take 
place  are  less  important  organs  for  the  existence  of  the  individual, 
and  lastly,  because  the  less  virulent  bovine  bacillus  is  the  active 
causative  agent. 

In  the  mixed  form  sometimes  the  symptoms  of  one  form, 
sometimes  those  of  another  appear,  and  are  indistinguishable  one 
from  the  other. 

As  hitherto  sufficient  care  has  not  been  taken  to  ascertain  with 
which  form  we  have  to  do  in  single  cases,  but  as  all  have  been 


SYMI'JO.MS  l8l 

joined  togelhcr  under  llie  general  heading  "  Scrofulosis,"  llie 
character  of  each  symploin  has  not  been  indicated  with  tliat  pre- 
cision which  in  (he  interest  of  (hagn(jsis  would  he  fU-siralde. 

A.     LOCAL  SYMPTOMS   IN   THE   SKIN. 
(1)  Non-tuberculous  Form. 

Non-sjjecific  shin  alfeclions,  \vhi(h  are  the  first  signs  of  scrcjfu.' 
losis,  are  much  more  frequent  than  specific  tubercular  disease. 

For  the  sake  of  completeness  we  \\ill  mention  what  are, 
according  io  Czerny,  the  first  manifestations  of  the  exudative 
diathesis,  viz.,  affections  of  the  skin  and  mucous  membranes, 
although  they  do  not  exactly  belong  to  scrofulosis.     They  are  : 

A  mapped  tongue^  (lingua  geographica),  sometimes  the  first 
sign,  though  not  always  a  regular  one.  This  appears  without  pain, 
and  is  shown  by  exudation  and  severe  desquamation,  with  white 
streaks  in  the  mucous  membrane  of  the  tongue  and  prominence  of 
the  papillae.  The  symptoms  disappear  of  themselves,  but  return 
after  some  days  or  weeks. 

Seborrhoea,  which  appears  in  infancy,  often  in  the  first  week 
of  life;  scales  of  a  dirty  grey  brow^n,  which  adhere  closely,  occur 
(even  in  children  who  are  kept  clean),  especially  about  the  head ; 
after  removal  of  the  scales  by  means  of  ointment,  the  hyperasmic 
skin  underneath  either  becomes  again  covered  with  scales,  or  it 
exudes,  especially  in  fat  children,  a  crust  is  afterwards  formed,  and 
there  may  be  secondarv  infection  and  eczema. 

Milk-scurvy,  also  appearing  in  infancy,  exhibits  itself  as  a 
marked,  sharply-defined  redness  and  scaliness  on  the  skin  of  the 
cheeks,  and  about  the  auricle,  which  after  a  time  disappear ;  it  is 
accompanied  by  loss  of  weight.  The  itching  now  and  then  con- 
nected with  it  leads  to  scratching,  loss  of  epithelium,  secondary 
infection,  and  eczema. 

Prurigo  (strofulus  or  urticaria  infantilis)  shows  itself  generally 
after  the  first  year,  and  may  last,  with  interruptions,  for  years.  It 
appears  chiefly  in  fat  children,  especially  about  the  hips,  in  large 
patches  of  reddish  weals  like  insect  bites.  The  redness  or  swelling 
disappears  after  a  day  or  two,  and  leaves  for  a  time  a  coarse  wartv 
infiltration  ;  in  thin  children  the  redness  is  not  so  decided.  In  this 
case  also  secondary  infection  and  eczema  is  induced  bv  irritation 
and  scratching. 

Intertrigo  and  soreness,  especially  behind  the  ears,  in  the  folds 

'  Lublinski  considers  that  a  mapped  tongue  (as  noted  in  fifty  cases) 
is  hereditary  (running  in  families),  and  denies  any  connection  with  the 
exudative  diathesis. 


1 82  SCROFLLOSIS 

of  the  neck,  armpiis,  Xc.  Hairiness  between  the  shoulder-blades, 
about  the  elbows,  and  on  ihe  ihii^lis.  and  furihcr  s\inpioms,  such 
as  phlvctena\  circular  caries  of  the  teeth,  lK.c.,  are  decitled  si^ns 
of  scrofulosis  in  our  sense. 

Eczema  is  the  prin(.-ipal  skin  alTection  amongst  scrofulous 
persons,  and  is  to  the  skin  what  catarrh  is  to  the  mucous 
membranes. 

As  already  remarked,  these  skin  aftections  have  no  specific 
signs  by  which  to  distinguish  them  from  similar  diseases  in  non- 
scrofulous  individtials,  btit  proclaim  their  connection  with  scrofu- 
l(\sis  onh-  b\"  their  obstinac\'  and  their  frequent  recurrence.  They 
occur  chiefly  on  the  face,  and  especially  at  those  points  most 
exposed  to  mechanical  injury,  where  transition  from  skin  to  mucous 
memlirane  takes  place,  at  the  entrance  of  the  mouth  and  nose;  on 
the  eyelids,  on  the  scalp,  and  behind  the  ears,  on  the  hands  and 
fingers,  red  swellings  occur  irregularly  scattered,  and  almost 
always  accompanied  by  intense  itching  (eczema  papulosum).  On 
account  of  the  severe  exudation  we  meet  with  blisters,  sometimes 
of  large  size,  either  transparent  and  clear  (eczema  yesiculosum), 
or  with  muddy  purulent  contents  from  the  absorption  of  cell 
elements  (eczema  pustulosum).  If  the  blister  bursts,  a  red,  exud- 
ing, excoriated  surface  appears,  and  the  secretion  dries  and 
becomes  a  cloudy  yellow  colour,  or  if  the  blood  from  the  hypera?mic 
capillaries  is  mixed  with  it,  a  brownish  scab  forms,  under  which, 
if  it  adhere  closely,  the  secretion  may  be  retained  with  injurious 
consequences.  At  a  later  stage  the  secretion  becomes  less,  and 
the  surface  drier,  scales  are  formed,  some  of  which  fall  off ;  at  last 
new  skin  is  definitely  formed  oyer  the  infiltrated  area. 

CEdema  and  chronic  swelling  take  place  at  the  seat  of  the 
eczema,  the  face  becomes  puffy,  the  nose  thick  and  swollen,  the 
lips  puffy  and  dry ;  at  the  corners  of  the  mouth  and  on  the  upper 
lip  are  obstinate  cracks,  which  bleed  easily,  and  the  facies  scrofu- 
losa  is  engendered  ;  sometimes  all  stages  are  observed  simultane- 
ously, but  the  impetiginous  form  of  eczema  is  found  especialb' 
frequently  in  scrofulous  individuals,  as  well  as  ectln-ma,  chiefly  on 
the  back,  buttocks,  and  thighs,  which  often  turns  to  sharply- 
defined  ulceration,  in  many  cases  healing  ^yith  difficulty  (Henoch). 
Perspiration,  uncleanliness,  and  want  of  care  favour  these 
affections. 

Eczema  is,  as  a  rule,  not  of  a  scrofulous  nature  even  in  tuber- 
culo-scrofulous  persons,  but  is  induced  or  maintained  by  oth?r 
bacteria,  pus  cocci,  &c. 

The  accidental  appearance  of  tubercle  bacilli  (Demme,  Volk- 
mann,    Ritter)  can   only  be  considered  an   exception.      We  may 


SYMI'KJ.MS  183 

suppose  lli.'il  111'-  niimcrons  opr-n  places  of  f(/.cm;y  f;iriliialc  the 
cnlry  of  IiiIxm-cIc  hncilli  ;  hiil  generally,  as  in  <  ;ii;irili  < >\  ilic  mucous 
in('inl)i\'in('S,  llic  h.iciili  \\lii(li  li,i\«-  hccn  dcposiicd  upon  tlieseare 
either  washed  awa}-  by  the  ph^ntifid  scrici  inns  of  the  surface,  or 
else  incrusted  ;  in  any  case,  Ihey  ar<-  icudcicd  harmless. 

Unna  dislinj^uishcs  in  (hil(hi-n  ,-i  1  iilxi' nlo-scrr^fulous  or 
scrofulous,  and  a  nervous  d<'ntilion  ec/.enia ;  the  former  is  mei 
with  on  the  nose,  eye,  ear,  head  and  mouth,  with  impetiginous 
characters;  lIic  lallcr  on  boih  cheelvs,  the  back'  of  \\\(:  hands, 
symmetrically  on  I  he  forehead  and  chin,  hrst  as  ilching  papules 
or  swellings,  which  undergo  further  changes  as  a  result  of  scratch- 
ing, and  are  repeated  at  each  recurrence  of  dentition. 

Eczema  and  erythema  arise  on  the  nose  and  ear  mving  to  the 
skin  being  irritated  by  the  acid  secretion  which  exudes  with 
catarrh  ;  a  thickening  of  the  skin  often  supervenes. 

We  often  find,  especially  in  children  who  are  not  kept  clean, 
multiple  small  skin  abscesses,  suppuration  in  several  places  one 
after  the  other,  caused  by  the  staphylococcus  aureus. 

Sittler  mentions  roundish,  rather  sharply-defined  patches  with 
small  scales  on  the  mucous  membrane  of  the  cheeks  of  scrofulous 
persons,  which  disappear  after  a  few  days. 

(2)  Tuberculous  Form. 

Lupus. — Lupus  is  chiefly  situated  on  the  face,  the  entrance  to 
the  nose,  in  the  neighbourhood  of  fistula?,  more  rarely  on  the 
hands  and  other  places.  It  appears  as  a  nodule  the  size  of  a  pin's 
head,  or  a  hemp  seed,  of  dark-red  or  vellowish-brown  colour,  at 
first  isolated,  but  afterwards  scattered  in  groups,  or  coalescing;  at 
first  deposited  in  the  tissue  of  the  skin  as  a  reddish-brown  patch 
(lupus  maculosus),  then  projecting  above  the  level  of  the  skin. 
When  pressed  under  a  glass  the  lupus  nodules  are  distinctlv  con- 
trasted as  yellowish-grey  spots,  reminding  one  of  sugar-candv. 
The  surface  is  smooth  and  shiny,  or  covered  with  scales,  the 
epithelial  growth  warty.  At  the  edges,  which  are  generally  semi- 
circular, a  peripheral  spread  of  the  nodules  may  be  observed  (lupus 
serpiginosus),  or  the  nodules  may  be  in  a  state  of  disintegration ; 
ulceration  may  arise  as  the  result  of  secondary  infection  (lupus 
exulcerans),  having  a  soft  circumscribed  edge  and  suppurating 
base,  which  easily  bleeds,  granulates,  or  becomes  covered  with  a 
yellowish-brown  crust,  or  thick  scab,  whilst  in  the  central  parts  a 
white  irregular  scar  is  formed.  Xow  and  again  we  see  prominent 
granulations  resembling  a  tumour  (lupus  tumidus) ;  on  the 
extremities  there  may  even  be  changes  resembling  elephantiasis. 


184  SCROFULOSIS 

At  a  later  stage  of  its  very  tedious  course  one  side  Avill  often 
heal,  whilst  the  lupus  on  the  other  side  extends  into  the  upper 
layers  of  the  skin,  or  attacks  the  hypodermic  tissues  and  the  deeper 
parts;  this  leads  to  extensive  destruction,  and  in  the  face  to  terrible 
disfigurement,  such  as  ectropion  of  the  eyelids  and  lips,  falling 
in  and  deformity  of  the  nose,  pear-shaped  enlargement  of  the 
lobes  of  the  ears,  destruction  of  the  auricle,  &c. 

Scrofuloderma. — Scrofuloderma,  which  by  its  structure  and 
the  demonstration  of  tubercle  bacilli  is,  in  contrast  to  lupus,  more 
sharply  defined,  and  is  described  by  Neisser  as  a  subcutaneous 
granuloma,  is  developed  alone,  or  in  groups,  in  the  cellular 
tissues  of  the  true  skin,  and  appears  at  first  as  a  hard  nodule  under 
the  loose  skin ;  if  there  is  no  absorption,  stretching  and  thinning 
of  the  skin  slowly  takes  place  later ;  this  either  gives  way  or  a 
roundish  softened  lump  the  size  of  a  pigeon's  egg  appears,  the 
so-called  cold  subcutaneous  abscess — the  gomme  scrofuleuse  of  the 
French  (Despres,  Besnier) — and  its  further  course  proceeds  with- 
out trouble  or  pain.  Scrofuloderma  is  either  associated  with 
lupus,  by  the  bacilli  which  have  been  taken  up  in  the  lymph- 
stream  depositing  themselves  and  proliferating  in  their  normal 
course  in  the  lymph  vessels  or  in  the  subcutaneous  lymph  glands, 
or  sometimes  a  tuberculous  fistula  is  formed  from  a  deep-lying 
scrofulous  bone  focus.  At  a  further  stage  of  its  slow  course  the 
skin  which  has  been  raised  from  the  tissues  lying  beneath  it  is 
blended  with  the  scrofuloderma,  becomes  thin  as  paper,  of  a 
bluish-red  colour,  and  breaks  down,  a  thin  fluid  resembling  whey 
is  discharged,  and  afterwards  a  round  tumour  is  formed,  with 
flaccid  walls  and  deeply  undermined,  a  so-called  scrofulous  skin 
ulcer  (scrofuloderma  ulcerosum),  which  tends  to  serpiginous 
extension  and  occurs  in  the  main  as  a  spongy  granulation  tissue, 
with  tubercles  scattered  about  in  it.  According  to  the  conditions 
found  bv  Leistikow,  who  demonstrated  the  Staphylococcus  aureus 
(by  a  development  in  culture)  as  well  as  the  tubercle  bacillus  in 
scrofuloderma,  at  the  base  of  a  nodule  whose  surface  was  entirely 
intact,  it  may  be  supposed  that  now  and  again  we  have  to  do  with 
mixed  infection. 

TUBERCULIDES. 

Besides  the  classical  bacillary  skin  tuberculosis,  lupus  vulgaris 
and  scrofuloderma,  the  scrofulous  nature  of  which  has  long  been 
attested,  other  skin  diseases  have  very  recently  (hardly  a  decade 
since)  acquired  symptomatic  importance  for  scrofulosis,  which 
clinicians  formerly  passed  over  w-ithout  noticing  and  which 
awakened  but  little  interest  even  for  dermatologists. 


SYMI'TO.MS  1H5 

I  refer  lo  lliose  skin  processes  ilr-fined  by  C".  B<je(;k  as  luber- 
cLiloLis  exanlliemata,  wliicli  Darier  comprised  under  the  generally 
accepted  term,  "skin  liilxrculides,"  viz.,  lichen  scrofulosorum, 
folliculitis,  erythema  induralimi,  lo  which  recently,  and  apparently 
rightly  lupus  erythematodes,  pityriasis  ruhra  of  Ilebra,  lupus 
pernio,  &c.,  have  been  added. 

We  have  especially  to  thank  Hocck,  Darier,  Klingmiiller, 
Jadassohn,  Zieler,  Alexander,  and  others  for  a  more  exact  know- 
ledge of  these  diseases. 

Their  frequent  appearance  in  tuberculous  individuals  showed 
their  connection  with  tuberculosis  (Boeck).  \n  many  cases 
bacilli  were  demonstrated,  and  apparently  more  frequently  since, 
according  to  Much,  investigations  have  been  made  by  Gram's 
method. 

The  positive  cutaneous  reaction  indicates  their  tuberculous 
nature  (especially  local  reaction,  which  is  common),  and  the  similar 
reactions  with  tuberculin  injection,  or  v.  Pirquet's  papule  reaction, 
and  the  observation  that  after  the  cutaneous  tests  entirely  similar 
erythematous  tuberculides,  such  as  lichen  scrofulosorum,  appear 
at  or  near  the  point  of  injection  (Moro,  Pfaundler,  Klar,  and 
others) ;  also  their  appearance  directly  on  an  infectious  malady, 
such  as  measles,  &c.  (Messa  and  others). 

Their  mode  of  production  will  occupy  our  attention  later ;  we 
will  here  only  investigate  the  symptoms  and  establish  their  con- 
nection with  tuberculosis,  or  tuberculo-scrofulosis. 

A  strict  separation  cannot  always  be  made,  as  numerous 
intermediate  grades  and  transitions  are  often  present  in  the  same 
patient ;  a  clear  division  is  often  rendered  very  difficult  by  the 
abundant  use  of  special  terms  having  the  same  meanings  without 
any  evident  necessity  for  so  doing,  a  custom  which  does  not 
increase  the  interest  of  the  practitioner  in  the  matter. 

Lichen  scrofulosorum  occurs  on  the  trunk,  rarely  on  the 
extremities  (Combv),  especially  in  children  with  older  latent 
tuberculous  lesions  and  also  with  intercurrent  affections  (measles, 
&c.).  When  they  spread  they  are  found  as  isolated,  clearly- 
defined,  circular  groups  of  the  size  of  a  millet  seed  or  a  pin's 
head,  somewhat  raised  above  the  level  of  the  skin,  but  the  nodules 
or  papules,  which  are  of  a  yellowish-brown  colour,  though  some- 
times bright  red,  are  flat,  and  occasionally  conical.  They  start 
from  a  follicle  or  near  one  (Kaposi)  and  render  the  skin  rough 
and  greasy.  On  the  surface  they  are  covered  with  a  small  scale, 
sometimes  with  a  little  pustule  the  size  of  a  poppv  seed,  which 
dries  and  leaves  behind  a  yellowish-brown  crust. 

Under  the  pressure  of  a  lens  the  efflorescence  becomes  paler 


lS6  SCROFULOSIS 

and  appears  as  a  tinv  l^rownish  spot.  After  weeks  or  months  spon- 
taneous in\-olution  lakes  place,  the  spots  become  paler,  disappear, 
or  leave  a  little  pigmented  spot  or  an  atrophic  depression  ;  m  rare 
cases  they  disintegrate  and  form  small  ulcers.  As  they  run  their 
course  without  inducing  any  disturbance  and  generally  without 
itching  they  are  easih'  oxH'rlookcd  (gixMng  rise  to  the  idea  of 
frequent  recurrence). 

In  several  cases  besides  the  conical  forms,  Schurmann 
describes  flat  nodules,  which  are  distinguished  from  the  typical 
form  by  size,  colour  and  polish. 

In  the  lichen  scrofulosorum  (tuberculosis  miliopapulosa 
aggregata)  of  Neisser,  epithelioid  and  giant  cells  are  found  histo- 
U)gicall\'  (Jacobi,  Lesselliers) ;  Klingmiiller  found  perivascular 
inflammation  alone  eleven  times  in  sixteen  cases,  Jacobi  and  Wolff 
succeeded  in  demonstrating  bacilli,  Pellizari  and  Haushalter's 
experiments  on  animals  gave  positive  results  (w'ith  Hallopeau  and 
Bureau  these  were  negative).  The  occurrence  of  lichen  after 
cutaneous  tuberculin  tests  characterizes  it  as  being  connected  with 
tuberculosis  (Moro  and  Leszczynski),  see  also  Comby,  Symoneaux 
and  Xobl.  Whether  lichen  is  of  a  tuberculo-toxic  nature  or 
whether  it  is  induced  by  weakened  or  dead  bacilli,  as  affirmed 
by  Jadassohn  and  Escherich,  and  especiallv  by  Neisser,  is  of 
minor  importance  in  relation  to  the  question  in  hand. 

FollECUlitis. — Papules  often  appear  in  batches  and  svmmetri- 
cally,  especially  on  the  edges  of  the  auricle,  on  the  face  and  fore- 
head, at  the  elbows,  the  ulnar  edge  of  the  forearm,  back  of  hands 
and  fingers,  the  knees,  thighs,  shins,  and  insteps;  at  first  the_y  are 
deep  in  the  skin  and  then  come  to  the  surface,  they  can  be  better 
felt  than  seen  and  \"ary  in  size  from  a  millet  seed  to  a  pea,  their 
colour  is  deep  red  merging  into  blue,  their  appearance  is  often 
preceded  by  pain  at  the  affected  part.  After  two  to  five  weeks 
they  disappear  leaving  no  trace,  or  they  leave  behind  a  patch  of 
brownish  colour;  sometimes  small  pustules  are  left,  the  heads  of 
which  contain  pus;  now  and  then  a  hard  scurfy  depression  forms 
which,  after  disintegration  and  involution,  leaves  little  white- 
pitted  scars  which  can  be  recognized  years  after  and  give  the  ears 
a  jagged  appearance. 

Folliculitis  is  identical  with  the  form  first  described  by  Boeck 
(1880)  as  lupus  erythematosus  disseminatus,  w-hich  is  again  distin- 
guished from  the  lupus  ervthematosus  disseminatus  described  by 
Kaposi,  but  it  is  the  same  as  the  affection  described  by  Brocqu  as 
the  folliculites  disseminees  symmetriques  des  parties  glabres  a 
tendances  cicatricielles,  for  which  Bronson  chose  the  name  acne 
\-ariolif()rmis ;    TAi]\'asiewicz   used   the  term    folliculitis  exulcerans, 


SYMI'IOMS  iH; 

whilsl  I'olliizcr  called  il  li\(lni(l(;nili.s  d<;struen.s  suppurativii,  bul 
JJubicnilli  (,-iil<'(l  il  li\(li<)s.-i(|i'nilf\s  suppuralives  dissj-mint'-cs.  I 
am  sorry  nol  lo  Ix-  able  lo  ^i\c  other  terms  for  this  malady  except, 
those  (jf  pnpiiln-nc(  roi  i(  I  iilxTciilides  and  granulom*'  innomine 
(IvCrredc  and  Marl  iiid )  and  I  iibi-iculides  acneiffjrmes  el  necro- 
tiques  (Bureau).  (See  Boeck,  "  Die  Exantlu-me  dcr  Tuberculose," 
S.  7,  cju.  lo). 

Neisser,  JuHusljcri;-  and  Alexander  have  foun(]  a  positive 
tuberculin  reaction  to  ix-  followed  i)y  f(jlliculilis-papulonecrolic 
tuberculides  (Bartlielemy).  Zieler,  in  contradiction  to  Piiiiippson, 
could  not  confirm  the  presence  of  baciUi  either  microscopically 
or  by  inoculation.  The  form  of  the  efflorescence  was  termed  bv 
some  authors  tuberculous  or  tuberculoid  (Macleod,  Oronsby, 
Alexander,  Hallopeau,  Tenneson  and  others). 

Recently  acid-fast  bacilli  were  demonstrated  by  Leiner  and 
Spindler  without,  however,  the  granular  form  described  by  Much, 
and  in  four  cases  inoculation  had  positive  results.  Burnet  had  a 
similar  experience  (see  also  Darier  and  Walter). 

The  following  are  described  as  special  forms. 

Pustulo-necrotic  tuberculoids,  or  ecthyma  scrofulus  (Kren), 
isolated  nodules  which  change  after  one  or  two  days  into  blisters 
containing  pus,  similar  to  impetigo;  the  blister  often  has  a  thick 
covering.  When  this  falls  off  a  loss  of  substance  takes  place 
leaving  a  sharp  edge  which  heals  by  granulation  and  forms  a  scar 
similar  to  small-pox. 

Papulosquamous  skin  tuberculides  are  often  isolated  but  are 
sometimes  numerous  and  of  the  size  of  a  pin's  head  to  a  hemp 
seed,  the  papules  are  slightly  prominent  at  first,  of  a  bright  red 
colour,  after  a  few  days  becoming  livid ;  in  the  centre  a  brownish 
scale  or  scab  forms,  often  having  fine  projections,  on  being  rubbed 
off  a  cone-shaped  depression  with  dry  base  is  left ;  often  there  is 
no  scab  and  a  shallow  depression,  or  simply  a  loss  of  substance 
with  clearly-defined  edge,  is  left. 

Hamburger,  who  emphasizes  the  appearance  of  the  affection 
especially  in  infants  and  its  diagnostic  importance,  mentions  as 
characteristic  the  lack  of  tendency  to  ulceration,  the  central  depres- 
sion, the  livid  brownish  colour  and  the  glazed  appearance  caused 
by  the  distension  of  the  skin.  Latemer  has  found  tubercle  bacilli 
and  had  positive  results  with  inoculation. 

Acne  scrofulosorum  and  folliculitis  scrofulosorum  are  in- 
cluded here. 

Erythema  induratum  forms  hard,  rough  painless  nodules  in 
the  skin,  the  size  of  a  cherry  to  a  walnut,  sometimes  flattened,  of 
a   purple  or  livid  appearance,    chiefiy  on   the  lower  extremities. 


1 88  SCROFULOSIS 

especially  on  ihe  calves  of  the  legs,  seldom  on  the  upper  extre- 
mities; it  occurs  especially  in  young  girls,  but  also  in  the  male 
sex  (Hutchinson,  and  Co'lcott  Fox);  they  can  last  months,  e\en 
years,  without  change  and  generally  end  by  absorption,  seldom  in 
softening  and  discharge,  with  the  formation  of  a  shallow  or  deep, 
obstinate,  often  painful  ulcer  (Hutchinson,  Sbllner,  and  others). 
Iodide  of  potassium  is  said  to  be  harmful ;  the  horizontal  position 
has  a  beneficial  effect. 

Erythema  induratum  (Bazin)  shows  its  connection  with  tuber- 
culosis by  a  positive  cutaneous  reaction  (Jadassohn,  Harltung, 
and  Alexander)  and  the  disappearance  of  the  eruption  after 
tuberculin  injection.  Hidaka  has  found  bacilli.  The  inoculation 
of  animals  with  particles  of  the  lesion  leads  to  tuberculosis 
(Thibi^rge,  and  Ravaut,  Sollner,  Colcott  Fox,  and  Carle). 

Its  coincidence  with  other  tuberculous  eruptions  or  internal 
tubercle  points  to  its  tuberculous  nature  (Schidacki,  Thibi^rge, 
and  Gastinel,  Carle  and  Kuznitzky),  but  apparently  this  does 
not  agree  with  every  case.  Clemens  could  demonstrate  no  bacilli, 
either  with  antiformin  or  by  experiments  on  animals. 

In  lupus  erythematosus  (or  erythema  perstans)  the  frequent 
accompaniment  of  tuberculous  skin  and  other  affections  proclaims 
its  tuberculous  nature  (C.  Boeck,  Hutchinson,  Besnier,  Herx- 
heimer.  Roth,  and  Saalfeld).  Arndt  and  Hidaka  found  bacilli, 
but  Brocqu,  Finger,  Kreibich,  Kraus,  Bokac  and  Robbi  attribute 
it  to  various  causes,  only  tuberculosis  amongst  others.  Neisser 
denies  direct  connection  with  tuberculosis. 

Observations  such  as  Polland's  lupus  erythematosus  occurring 
with  acute  miliary  tuberculosis,  Appel's  case  in  which  the  disease 
was  cured  by  tuberculin,  and  Arndt's  demonstration  of  tubercle 
bacilli  make  the  tuberculous  nature  probable  to  a  certain  extent, 
but  experiments  on  animals  had  negative  results  (see  Reitmann 
and  Zumbusch,  Campana,  Hiibner,  Kyrle,  and  Schonfeld). 

Lupus  follicularis  disseminatus  appears  acutely  or  subacutely 
as  a  brown  livid  red,  remarkably  soft  nodule,  the  size  of  a  pin's 
head  or  a  pea,  on  the  face. 

In  lupus  follicularis  disseminatus  faciei  (lupus  miliaris)  there 
are  histologically  nodules  which  are  certainly  lupus  (Leiner  and 
Spieler  and  Loewenberg),  and  tubercle  bacilli  have  also  been 
demonstrated  (Schlassberg,  Finger,  Bellmann  and  Arndt) ;  besides 
inoculations  have  been  attended  with  positive  results  (Jadassohn). 

Cohn  and  Opificius  also  take  the  tuberculous  nature  of  the 
affection  into  account,  whilst  Delbanco  considers  it  assured  by  the 
observations  of  Reunert,  who  brought  about  healing  by  new 
tuberculin. 


SYMI'JfJMS  189 

liocck's  sarcoid  is  an  aHc(lioii  beginning  in  ilie  !<nvrT  layers 
ol'  llic  skin,  wliicli  forms  liiin  nfjdulcs  and  soniclini'-s  di((ns'- 
inlillration  on  llie  lace,  Uie  surface  of  llic  skin  is  bright  red,  livid, 
later  beccjming  yellovvisli-brown  and  tensely  streiclied  over  tlie 
seat  of  infiltration. 

Opificiiis  found  in  Boeck's  benign  miliary  lu[)oid  (ilie  con- 
nection of  wliicli  with  tuberculosis  was  accepted  by  Kreibich  and 
Alfred  Kraus),  in  one  case,  decided  reaction  to  tuberculin  and 
epithelioid  cells  but  no  bacilli. 

r.upus  pernio,  the  infiltrations  of  which  resemble  chilblains, 
forms  bluish-red  or  pale  blue  puffy  prominences  on  the  surface, 
often  feeling  rather  soft,  but  at  times  brawny,  especially  on  the 
ears,  nose  and  hands. 

The  tuberculous  nature  of  lupus  pernio  is  accepted  by  many 
authors  as  probable  (Polland,  and  also  Jarisch).  Kreibich,  Kuhl- 
mann,  and  Zieler  deny  it,  because  neither  the  antiformin  method, 
nor  that  of  Ziehl  or  Much,  yielded  tubercle  bacilli,  and  inoculation 
was  without  result;  Bogolepow  has  demonstrated  tuberculosis 
histologically,  but  met  with  a  negative  conjunctival  reaction. 

Acneiform  tuberculosis  consists  of  numerous  bright  red 
nodules,  the  size  of  a  hemp  seed  or  a  pea,  rising  gradually  from 
flat  efiliorescences,  often  symmetrically,  on  prominent  parts  and 
on  the  abductor  surface  of  the  extremities,  on  the  elbow,  hand 
and  ankle,  rarely  on  the  face.  The  nodules  turn  bluish  and 
become  flat  in  the  centre,  after  turning  yellow  they  at  last  dry 
up  to  black  deep-seated  crusts.  A  scar  filled  with  blood  is  left 
with  a  bluish  hypera^mic  areola  which  later  becomes  white  and 
faded. 

Acnitis  is  also  reckoned  by  many  amongst  the  tuberculides 
(Hallopeau  and  others),  but  sure  grounds  are  wanting  (Barthe- 
lem\',  Pick  and  Alexander). 

Pityriasis  rubra  of  Hebra,  the  connection  of  which  with 
tuberculosis  is  noted  by  Jadassohn,  Wertheim  and  Finger,  and 
Bruusgaard  was  found  w-ith  tuberculosis  of  the  Ivmph  glands,  bv 
Miiller,  Halle,  and  Fabry.  Tubercles  and  bacilli  were  in  manv 
cases  demonstrated,  they  were  found  chiefly  in  chronic  tuber- 
culosis, or  tuberculosis  under  the  guise  of  pseudoleuka?mia,  but 
it  is  not  yet  decided  if  they  are  connected  with  each  other. 

Eczema  scrofulosorum  remains  to  be  mentioned ;  it  occurs 
especially  in  young  adults,  as  more  or  less  infiltrated  red  or 
yellowish  spots  or  raised  surfaces  often  onlv  forming  scales,  but 
sometimes  moist  and  covered  with  a  crust ;  on  the  lower  extremities 
especially  we  find  large  or  small  papules,  passing  into  pustules. 
Places  of  predilection  are  the  anterior  and  hinder  surfaces  of  the 


1 90  SCROFULOSIS 

tliorax,  ihe  DUier  side  of  ihe  upper  arm,  and  pari  of  tlie  pars 
capillala. 

Scleroderma  is  also  found  connected  wiiii  luherculosis.  In 
five  cases  Reines  obtained  percutaneous  luljerculin  reat'tion  and 
in  four  cases  certain  lul^erculosis.  We  must  also  include  the 
parapsoriasis  of  Br(,)ccju,  which  \'erotli,  on  the  basis  of  histological 
findings,  termed  j'jsoriasiform,  papulosc]uamous  tuberculide. 
SuUon  accepted  the  tuberculous  nature  of  lichen  nitidus. 

For  the  bearing  of  the  tuberculin  cutaneous  reaction  on  this 
subject,  see  pp.  19  and  258. 

As  already  mentioned,  the  skin  tuberculides  do  not  always 
forni  sharpK--defined  groups,  but  many,  such  as  folliculitis, 
acute  luemorrhagic  miliar\'  tuberculosis  of  the  si<in,  and  lupus 
miliaris  disseminalus,  often  exhibit  transition  foi'ms  (Leiner  and 
Spieler). 

Gaucher  described  pustulo-ulcereuse  tuberculosis  as  a  sort 
of  impetigo  which  leaves  ulcers,  the  secretion  of  which  induces 
tuberculosis  running"  a  slow  course  when  injected  into  animals; 
Doutrelepont  has  made  a  similar  obser\"ation.  In  these  cases  we 
ha\e  probably  to  do  with  a  secondary  immigration  of  tubercle 
bacilli. 

Hallopeau  and  Bureau  define  as  acneiform  folliculitis  small 
pustules  on  the  site  of  which  crateriform  depressions  speedily 
appear,  leaving  later  scars  with  sharplv-marked  edges;  they  are 
dispersed  over  the  trunk  and  extremities,  sometimes  arranged  in 
groups,  and  followed  by  tuberculous  adenitis.  Thibierge  also 
describes  a  disseminated  folliculitis  with  tuberculosis  of  the  lymph 
glands. 

Persons  suffering  from  scrofulous  syphilis  often  show  a  small 
papulo-pustulous  scaly  exanthem  which  ends  with  dark  pigmenta- 
tion and  forms  a  scar;  giant  cells  have  been  found  in  it  (Neumann, 
Michelsohn,  and  Ehrmann).  Ehrmann  considers  the  exanthem 
to  be  a  direct  mixed  form  of  scrofulosis  and  syphilis. 

On  being  treated  with  mercury  these  eruptions  only  partially 
disappear,  the  rest  involute  only  with  cod-liver  oil. 

Iveloir  calls  attention  to  such  mixed  infections  in  glandular 
and  skin  affections  which  only  heal  by  antisyphilitic  and  anti- 
tuberculous  treatment. 

Opinions  differ  on  the  origin  of  tuberculides.  The  theory 
of  their  being  the  products  of  metabolism  and  of  destruction 
of  the  tubercle  bacilli  which  have  entered  the  circulation,  the  toxin 
tlieory  of  Hallopeau,  found  followers,  especially  when  Kling- 
miiller  succeeded  in  producing  changes  similar  to  tubercles  by 
injecting  old   tuberculin,    free   from   bacilli   and    passed   through 


SYAII'JXJM.S  I'ji 

por(jLi.s  fillcis,  inio  llif  skin,  and  \\lii(li  on  IihiImt  I  uIj'TciiIiii 
injection  gave  a  h \  pcia'niic  rf-aclion. 

In  opjxjsilion  lo  (lie  oi^jccticjus  oi  Jadassohn,  PicU  and  JJaf,'ls, 
Zieler  has  dcmonslralcd  ihaL  liibcrcuHn,  free  from  bacilli  and  from 
"  s|)lill('i'  "  bacilli,  can  induce  i^cnninc  I  iibi  r(  nloiis  tissue  structure 
which  on  further  tuberculin  injections  shows  typical  focal  reaction. 

The  late  effect  of  the  cutaneous  and  c(jnjtmctival  tests,  in 
conseciuence  of  which  lichen  and  similar  tuberculide  forms  some- 
times appear  in  distant  parts,  is  in  fa\our  of  the  toxin  theor\-. 

On  the  other  hand,  the  association  of  bacilli  in  the  production 
of  tuberculides  has  been  pro\'ed  in  a  numixr  ol  cases  (see  j).  247) 
by  their  dcnu)nstratit)n  microscopically,  which,  by  the  Irelp  of  the 
anliformin  method  and  Gram's  colouring  succeeds  much  more 
frequently  than  formerly. 

The  reactive  phenomena  appearing  after  the  cutaneous  test, 
V.  Pirquet's  papuhc  and  the  lichen  scrcjfulosorum,  which  appear 
occasionally  at  distant  points,  and  which  probably  owe  their 
production  to  the  effects  of  a  toxin,  are  distinguished  by  their 
speedy  disappearance.  As  a  rule  they  only  last  a  few  days  and 
seldom  more  than  a  week. 

From  this  we  may  suppose  that  tuberculides  are  of  purely 
toxic  origin,  last  as  a  rule  but  a  sliort  time,  that  the  efifect  of  the 
released  materies  morbi  is  soon  over,  and  the  changes  return  to 
the  normal  for  want  of  further  irritation. 

On  the  otlier  hand,  we  may  suppose  that  the  majority  of  per- 
sistent, often  even  obstinate  tuberculides  arise  through  the  associa- 
tion of  the  bodies  and  remains  of  bacilli,  the  further  protracted 
disintegration  of  which  impresses  a  permanent  character  on  the 
tissue  formed  by  them . 

The  question  whether  only  the  dead,  or  living  bacilli  also, 
are  the  supposed  causative  agents,  and  then  whether  the  bacilli 
are  weakened  or  fully  virulent,  is  much  more  important  both  in 
its  clinical  and  prophylactic  bearings. 

In  the  majority  of  cases  we  have  doubtless  to  do  with  dead 
bacilli  wliich  have  crumbled  away,  so  to  speak,  from  older  disin- 
tegrated foci,  and  which  enter  the  blood  passages  much  more 
easily  than  living  ones,  as  shown  by  numerous  negative  inocula- 
tion experiments. 

But  the  numerous  positive  results  after  inoculation  into 
guinea-pigs  show  that  living  bacilli  may  also  take  part  in  the 
formation  of  tuberculides;  still,  the  fact  that  we  have  to  do  with 
virulent  bacilli  for  man  also  is  not  conclusivelv  proved  even  bv 
experiments  on  guinea-pigs,  as  these  are  more  susceptible  to  the 
tubercle  bacillus  than  man,  and  accordinglv  it  is  not  proved  bv 


192  SCROFULOSIS 

the  results  obtained  by  Hildebrandt,  who  injected  the  blood  of  a 
patient  stiffering  from  erythema  nodosum  into  a  guinea-pig  and 
obtained  a  positive  result. 

Many  reasons  lell  against  the  complete  virulence  of  these 
bacilli. 

Firstly,  the  acknowledged  benign  character  of  their  products, 
the  tuberculides,  which  would  not  be  the  case  with  virulent  bacilli, 
as  we  have  to  do  with  a  great  number  of  children  in  earliest 
infancy,  when  they  are  most  unable  to  resist  virulent  affection. 
The  virulent  bacilli  as  a  rule  are  followed  by  the  most  serious 
consequences  and  do  not  confine  themselves  to  the  formation  of 
insignificant  nodules  which  after  a  shorter  or  longer  period  are 
absorbed  and  disappear. 

Secondly,  the  fact  that  the  tuberculides,  almost  without  excep- 
tion, onlv  appear  as  accompanying  phenomena  of  mild  forms  of 
glandular  tuberculosis,  of  scrofulosis,  and  sometimes  of  bone  and 
joint  tuberculosis,  whilst  the  fact  that  acute,  florid,  highly  virulent 
tuberculous  processes,  even  chronic  phthisis  itself,  are  but  rarely 
accompanied  by  tuberculides,  tells  against  the  virulence. 

Certainly  we  do  meet  with  cases  in  which  a  person  suffering 
from  tuberculides  (as  Boeck  says)  "often,"  many  years  later, 
becomes  one  of  the  multitude  affected  with  phthisis,  who  after  a 
time  succumbs  to  tuberculosis. 

But  this  is  no  proof  of  the  virulence  of  the  bacilli  present  in 
tuberculides,  for  it  cannot  be  proved  that  the  bacilli  which  cause 
death  are  descendants  or  collaterals  of  the  earlier  tuberculide 
bacilli.  We  know,  not  only  that  there  are  double  infections,  but 
that  they  are  even  tolerably  frequent,  and  so  in  such  cases  it 
remains  an  open  question  whether  a  former  less  virulent  infection, 
perhaps  of  bovine  bacilli,  from  cervical  or  mesenteric  glands, 
which  was  accompanied  by  tuberculides,  was  followed  by  an 
external,  later  highly  virulent,  fatal  infection  of  the  lungs.  We 
often  find  even  in  the  same  organ,  for  example,  in  the  lungs  and 
in  the  sputum,  human  and  bovine  types  side  by  side. 

Their  lesser  virulence  is  again  indicated  by  their  easy  dis- 
persal in  the  bodv  and  bv  the  frequent  recurrence.  For  the  less 
virulent  the  bacillus  the  slighter  is  the  reaction  of  tissues  at  the 
primary  focus,  therefore  the  easier  their  dispersal  and  their  passage 
into  the  blood.  We  see  that  in  the  rabbit  when  inoculated  with 
the  human  type  the  bacilli  quickly  disperse  in  the  blood  through 
the  glands,  whereas  usuallv  they  are  retained. 

Taken  altogether  we  are  led  to  the  supposition  that,  as  far 
as  living  bacilli  are  concerned  in  the  formation  of  tuberculides,  the 
slight  further  development  and  the  benign  course  do  not  depend 


SYMPTOMS  193 

on  an  increased  individual,  i^cixTal  or  local  pnv.'-i-  nl  resistance 
in  the  person  concerned,  hiii  m  ilic  avindence  ol  iIk-  Ijacilli. 

Tliat  which  dinercnlialcs  die  Luberculidc  from  die  true  form 
of  skin  tuberculosis  is,  amon,L,^st  otlier  dnngs,  first,  its  apparent 
dispersal  wilhout  selection  over  the  whole  of  die  body  in  sjnie  of 
certain  places  of  {oredilecliijn,  which  points  to  a  hiematfjgenous 
origin;  secondly,  its  extraordinary  chronic  course,  often  lasting 
years  and  decades,  ils  harmless  course,  and  the  frequent  spon- 
taneous recurrences;  diirdly,  the  frequent  lack  of  bacilli  and 
specific  tissue  changes,  which  recall  in  a  measure  the  lymphoid 
changes  obtained  by  Bartel,  by  the  inoculation  of  a\  iniU-ni  bacilli  ; 
fourthly,  the  temporary  ai)pearance  in  symmetrical  places,  on 
each  side  of  the  body,  widch  in  many  cases  leads  us  even  to  tjiink 
of  tuberculo-toxic  action  on  nerve  centres;  fifthly,  the  recurrence 
in  stages — in  short,  a  number  of  conditions  which  differ  from  the 
action  of  true  tubercle  bacilli. 

How  far  the  bovine  bacilli  from  an  older  lesir)n,  whicli  are 
continually  ingested  by  old  and  young  in  milk,  butter,  &c.,  how 
far,  perhaps,  special  tuberculous  strains  participate  has  not  as  yet 
been  investigated. 

Lewandowski  connects  the  formation  of  tuberculides  with  the 
phenomena  of  immunity,  and  believes  that  the  dissemination  of 
a  very  small  quantity  of  tubercle  bacilli  when  the  body  contains 
much  antitoxin  leads  to  tuberculides,  whilst  in  dissemination  of 
a  moderate  quantity  of  tubercle  bacilli  wdiere  there  is  but  slight 
antitoxin  formation,  muUiple  hfematogenous  lupus  is  induced. 
This  theory  is  based  and  extended  on  hypotheses  which  need 
further  confirmation . 

There  is  no  question  about  the  fact  that  we  are  far  from  the 
end  of  the  knowledge  which  it  is  possible  to  obtain  on  the  subject, 
and  I  am  inclined  to  think  that  a  further  study  will  give  us  many 
valuable  hints  for  the  complete  understanding  of  tuberculosis. 

B.— LOCAL    SYMPTOMS    IN  THE   MUCOUS  MEMBRANES. 

NOSE. 

Pyogenous  scrofulosis  shows  itself  in  the  mucous  membranes 
by  frequent  catarrh. 

The  mucous  membranes  of  the  nose  are  often  affected  as  a 
condition  of  obstinate,  easily  recurrent  cold  in  the  head  (chronic 
cold  in  the  head),  the  nose  is  frequently  obstructed,  a  quantity  of 
mucus  or  suppurative  secretion  is  discharged  (rhinitis  chronica 
purulenta)  which  irritates  the  entrance  to  the  nose  and  the  upper 

13 


194  SCROFULOSIS 

lip,  ihe  pans  become  reel  aiul  excorialeel,  tollowed  by  swelling 
and  eczema.  A  quanliiy  oi  yellowish-green  scab  is  deposited  at 
the  entrance  of  the  nose,  idle  lingers  often  occup}-  tiiemselves  with 
removing  it,  and  picking  the  nose  causes  new  infection. 

B\-  the  t>bstruction  in  the  nose  the  child  is  forced  to  breathe 
through  the  nlouth,  anel  thus  infection  of  the  deeper-seated 
respiratory  organs  is  faciliiaied.  if  this  condition  last  long  the 
mucous  membrane  thickens,  ihe  wlu)le  nose  is  permanently 
swollen,  and  l)ecomes  sensiiixe  to  the  touch,  a  stale  of  allairs  wiiicli 
is  considered  peculiaiK-  t-Jiaracteristic  of  scrofulosis  (Pins).  Some- 
times ulcers  are  formed,  in  rare  cases  the  process  attacks  the  peri- 
chondrium, the  nasal  cartilage,  the  septum  nasi  and  muscles,  and 
leads  to  deformity  of  the  nasal  framework.  The  extension  of  the 
destruction  to  the  ethmoid  and  perforation  of  the  hard  j)alate  has 
bee-n  observed  (Henoch  and  Stoerk),  but  in  such  deep-seated  cases 
it  may  be  supposed  that  we  are  dealing  with  lubercido-scrofulosis 
or  lupus  processes  and  not  w  itii  pyogenous  processes. 

Formerly  oza?na  (rhinitis  atrophicans  ftx'tida)  was  considered 
almost  pathognomonic  of  scrofulosis.  Some  (Zaufal)  attribute  !t 
to  an  abnormal  breadth  of  the  nasal  cavity  and  the  faulty  removal 
of  the  secretion,  others  (Loevenberg,  Rohrer,  and  'SI.  Hajek)  to 
a  specific  oz^na  coccus.  Scrofulosis  is  said  to  be  distinguished 
from  ordinary  ozccna  by  the  fact  that  in  the  former  the  atrophy 
proceeds  more  quickly. 

MOUTH  AND  PHARYNX. 

In  intimate  connection  with  this  chronic  nasal  catarrh  and 
suppuration,  perhaps  even  afded  and  caused  by  it,  we  meet  with 
the  well-known  growth  of  the  pharyngeal  tonsil,  the  so-called 
adenoid  vegetations.  Anatomical  proofs  are  wanting  for  Erdely's 
supposition  that  adenoids  are  generally  congenital  (see  also 
Czern\). 

Adenoids  in  a  form  resembling  cones  or  berries  deeply 
furrowed  or  spherical,  reddish  or  pale  red,  sometimes  covered  with 
tough  greenish-yellow  mucus,  fill  the  naso-pharyngeal  space 
entirely  or  in  part,  and  contract  and  embarrass  the  normal  respira- 
tory path,  and  themselves  induce  further  inflammatory  processes  in 
the  vicinity  of  the  Eustachian  tubes,  middle-ear,  nose  or  pharynx. 
The  principal  well-known  consequences  are,  open  mouth,  snoring, 
dull  toneless  speech,  disturbances  of  hearing,  and  now  and  again 
enuresis  nocturna,  arrest  of  physical  and  menial  de^'elopment 
(malformation  of  the  palate,  Guye's  aprosexia). 

The  tuberculous  form  of  scrofula  has  less  opportunitv  of 
making   itself   noticeable   in  the   nose  and    naso-phar^•nx   than    in 


S  N.Mr  I  O.MS  Jf^5 

other  inticoiis  incinhr.'inc.s.  'llic  low  bacilli  uitli  which  \v«*  have*  io 
do  in  naUiial  inlc(  linn  |)cnci rale,  a.s  has  been  l"rc(|iicnlly  r<'marl<ecl, 
the  more  pcniic-iblc  imicoii.s  ineinbrane  of  ihc  child  uidioiii  havinj,' 
projia scaled  immc{Hai<'l\  mi  .-Kcoiini  ot  dicir  slow  yrowlli,  and  only 
laler  find  a  rcsi  iiiq-pl-K c  11  a  bacillus,  from  special  circum- 
stances, shiiiikl  be  held  back,  a  siib-epii liclial  further  ad\anc<'  in 
the  extensive  meshes  of  the  lymph  paths  lakes  j^lace,  and  by  a 
superlicial  diss(;minaiion  lupus  occurs,  which  runs  its  course 
without  ])ain,  and  no  spiMial  sym|)toms  bcvond  hvpersecrelion. 
I  lie  real  destruction,  the  ulcer,  is,  in  die  mucous  membrane,  in  all 
parts  of  the  body,  whetiier  nose,  UKjulh,  genital  organs,  or  lungs, 
iiioic  a  [:»ecuHarily  of  later  years,  or  at  least  of  adult  life. 

Ozccna  is,  as  a  rule,  not  cjf  tuberculous  nature,  though  in  a 
few  cases  tubercle  bacilli  have  been  demonstrated  (Demme,  see 
also  p.  12).  X'olkmann  notes  the  occurrence  of  an  oz.'ena  tuber- 
culosa with  genuine  tuberculous  ulcers,  which  he  distinguishes 
from  the  general  and  more  frequent  rhinitis. 

In  many  cases  adenoid  ^•egetations  are  of  a  tuberculous 
nature,  but  this  condition  has  been  much  over-estimated.  In  fact, 
in  1,745  cases  the  tuberculous  nature  was  confirmed  in  onlv  4' i 
per  cent,  (see  p.  142).  On  the  basis  of  histological  investigations, 
Simon  believes  that  adenoids  have  no  connection  with  tuberculosis 
and  scrofulosis  (see  also  Sobernheim  and  Blitz). 

Whilst,  according  to  Roux  and  Roques,  tuberculous  neck  and 
bronchial  glands  were  mostly  present  \vith  adenoids,  Xobecourt 
and  Aptekmant  found  the  reaction  to  tuberculin  negative  in  57  per 
cent.  The  identity  of  hyperirophy  of  the  pharyngeal  tonsil  with 
scrofulosis,  which  Trautmann  recognizes,  cannot  be  considered. 
Nadoleczny  even  denies  a  special  frequency  of  adenoids  in 
scrofulosis  and  exudative  diathesis,  but  notes  at  the  same  lime 
their  general  great  dispersal  among  boys  between  6  and  7  years 
of  age,  94-7  per  cent,  (in  girls  S5'7  per  cent.);  according  to 
Senziak,  even  the  parents  exhibit  the  same  afTection. 

As  a  phenomenon  often  appearing  in  scrofulous  patients,  \ve 
must  specially  notice  in  the  mouth  and  pharvnx  angina,  that 
inflammation  of  the  tonsils,  so  liable  to  recurrence,  with  conse- 
quent hypertrophy.  Frequently  the  whole  area  of  the  pharvnx 
is  in  a  state  of  hyperplasia.  Contrary  to  the  opinion  received  bv 
laymen,  it  must  be  noted  that  even  highly  hypertrophied  tonsils 
cannot  be  felt  from  the  exterior ;  what  we  feel  are  chieflv  Ivmph 
glands.  The  most  noticeable  symptoms  are  the  nasal  tone  of  the 
voice,  snoring,  and  sometimes  reduced  power  of  hearing. 

The  occasional  demonstration  of  tubercle  bacilli  in  the  palatal 
tonsils  (see  pp.  140-142)  in  no  way  justifies  the  conclusion  often 


196  SCROI-'ILOSIS 

drawn  from  it,  ihai  ilir  swollen  lonsils  are  in  niosi  cases  luber- 
culously  alleclecl. 

The  leeih  of  scrofulous  persons  are  very  brittle  and  inclined 
to  caries,  a  symptom  the  peculiar  bearings  of  which  \ve  have 
aireadx'  liinied  ai  ahoxe  (see  p.    14J). 

Of  the  milk  teeth,  especially  the  upper  incisors,  Neumann 
Avas  the  first  to  describe  an  adherent  brown  or  greenish  dis- 
coloration of  the  teeth  near  the  gmn,  ^\llich  turned  into  caries 
encircling  the  crown  or  neck  of  the  tootli.  He  found  scrofulo- 
tuberculosis  is  nearly  two-thirds  of  the  clinical  cases  of  this  circular 
caries  (ami  lul^erculosis  ('^(Kst-iunrloii  in  nioi-c  than  halt).  When 
similar  adherent  greenish  layers  were  found  on  the  remaining 
teeth  three-ft)urlhs  of  the  cases  were  clinically  scrofulo-iuberculous. 

More,  amongst  others,  confirms  in  general  the  importance 
of  these  symptoms  in  the  tuberculous  form,  but  often  met  with  a 
negative  tuberculin  reaction,  in  genuine  circular  caries  28  per  cent., 
in  partial  caries,  namelv,  only  on  the  anterior  ])eriphery,  50  per 
cent.  Moro,  therefore,  considers  this  symptom  more  a  sign  of 
"  Ivmphatism,"  though  tuberculosis  may  have  helped  to  induce  it. 

Some  authors  (Ldri,  Cadier,  Hajek,  Revilloul,  <S:c.)  mention 
scrofulous  ulcers  in  the  pharynx,  and  describe  their  characteristics, 
flabby  granulations,  a  tendency  to  speedy  dispersal,  no  surround- 
ing reaction,  long  duration,  and  situation  on  the  posterior  side 
wall  of  the  pharvnx  near  the  origin  of  the  palato-pharyngeal  arch  ; 
on  healing  tiiev  mav  induce  partial  closing  of  the  naso-pharvngeal 
wall  bv  cicatricial  changes.  I  have  no  personal  experience  in  the 
matter,  and  it  is  uncertain  how  far  perhaps  tuberculous  or 
svphilitic  changes  may  be  concerned.  In  a  succession  of  manuals 
by  specialists  I  find  these  changes  are  passed  over. 

Retropharyngeal  abscesses,  which  are  often  observed  as  a 
consequence  of  scrofulosis,  arise  from  suppuration  of  the  small 
lymph  glands  on  the  anterior  part  of  the  cervical  vertebfce,  or 
from  periostitis,  or  caries  of  a  neighbouring *'ertebra.  Thev  occur 
most  frequently  before  the  second  year.  Choking  when  drinking, 
stiff  carriage  of  ilie  head,  especially  in  vertebral  caries,  and  nasal 
voice  point  to  it  and  demand  local  examination  ;  it  is  evidenced  on 
digital  examination  by  a  fluctuating  protrusion  of  the  posterior 
pharyngeal  wall. 

EAR. 

A  frequent  symptom  of  scrofulosis  is  clironic  suppurating 
middle  ear  inflammation,  middle  ear  catarrh,  and  catarrh  in  the 
neighbourhood  of  the  nose  or  tonsils,  sometimes  of  the  ordinary 
type,  sometimes  as  phenomena  consequent  upon  acute  infectious 


SYMI'TOMS  197 

diseases;  scarlcl  lever,  inc'islcs,  .sni.'ill-|in.\,  iiilliien/.a,  (liplitli<Ti;i, 
aiul  \\'li()()|)in<;-(  <»ii«4li  in;i\  Ix-  iiwiil  n  iiiri  |  ;is  llic  imr-,!  iinincdi.'ii'- 
ciiuses. 

On  aecoiml  nl  llic  I  ic(|iicn(;\-  of  mkIi  ngi-nc'ics,  ii  is  (lifficiilt  t'l 
continn  the  facL  how  i':\v  mk  li  a  disease  of  llie  middle  ear  can  he 
looked  upon  as  a  sym[)l()ni  of  sciofnlosis. 

In  the  acute  stage  of  middle  <'ai-  innammaiidn  iIk-  mosi  marked 
symptoms  are  boring,  throbl^ing  pain  in  (he  ear,  which  is  specially 
felt  when  clearing  the  throat,  and  on  any  movement  of  liie  head, 
will)  intervals  of  |)ainlessness ;  iIm-  inllaniniai  ion  exlends  to  the 
surrounding  parts,  and  is  accompanied  by  a  sense  of  fulness  in 
the  head  and  deafness.  Tlirougli  ilie  ear  speculum  we  see  the 
evidence  of  an  inflamed  hy|:)eraMnic  membiana  lympani  ;  it  shows 
a  convex  prominence  witli  swelling  and  oedema  of  the  adjoining 
cutis.  On  the  summit  of  the  prominence,  of  the  membrane,  the 
threatening  perforation  appears  as  a  light  yellow  spot.  Out  of 
the  small  opening  spontaneously  formed  a  more  or  less  abundant 
mucous  suppuration,  and  in  carious  processes  an  ichorous  secre- 
tion mixed  with  blood,  is  discharged.  Pain,  cerebral  symptoms 
and  fever,  if  present,  are  reduced,  or  if  they  continue  or  return 
point  to  the  retention  of  pus,  owing  to  premature  closing  up  of  the 
perforated  opening  or  to  inflammatory  irritation  of  the  bony  walls, 
to  complications  Avith  periostitis,  ostitis,  empyema,  caries  or 
necrosis. 

In  scrofulous  persons,  especially  in  those  who  are  debilitated 
or  cachectic,  the  secretion  will  often  take  months  to  cease.  The 
acuteness  of  hearing  may  indeed  be  restored,  but  often  the  process, 
especially  if  frequently  repeated,  turns  to  chronic  suppuration  of 
the  middle-ear;  when  ulceration  of  the  edges  of  the  perforation 
occurs,  considerable  defects  in  the  membrana  tympani,  or  growths 
in  the  mucous  membrane  (polypus  formation)  may  ensue.  In  the 
aural  passages,  especially  in  the  cavity  of  the  tympanum,  a  sup- 
purative secretion  mav  be  observed  which  now  and  then  dries  up 
to  a  vellowish-green  scab,  and  is  accompanied  by  a  fanid  odour. 
Facial  paresis,  reduction  or  loss  of  power  of  hearing,  dumbness, 
or  in  voung  children  deaf  mutism  may  appear  as  consequences. 

The  danger  of  meningitis,  a  brain  abscess,  a  sinus  phlebitis 
or  pv^mia,  any  of  which  may  appear  unexpectedly,  is  threatened 
until  the  middle  ear  suppuration  is  completely  healed. 

When  the  catarrh  of  the  middle  ear  is  not  accompanied  by 
inflammation  the  violent  pain  is  wanting,  complaint  is  only  made 
of  a  feeling  of  fulness  in  the  ear,  stuffiness  in  the  head,  subjective 
sensations  of  hearing-,  a  cracking  in  the  ear  when  swallowing,  and 
deafness.     The  membrana  tvmpani  is  nor  inflamed  or  swollen,  but 


IqS  SCROFULOSIS 

is  (.Irawn  in.  aiul  ihr  exiKlaiion  nia\-  oflen  he  seen  ihrough  it.  In 
the  drv  form  ihe  niemhrane  is  oflen  hardly  changed,  hut  later 
exhihils  as  a  consequence  an  opacity  antl  chalky  deposit,  a  drawing 
inwards,  and  atrophv,  and  during  ausculiation  on  catheterizing, 
instead  of  the  rustling  noise  heard  in  inoisi  caiarrli  we  hear  a  dry, 
whirring,  or  hai^sh  blowing  sound. 

I"]xlernallv  we  observe  in  the  ear,  especially  in  tonneciion 
with  ec/ema  of  the  auricle,  otitis  externa,  with  serous  purulent 
discharge,  such  as  follows  the  inlroduclion  of  foreign  bodies.  In 
the  chronic  form  we  get  a  malodDrous  \iscid  pus. 

A  rare  form  of  otitis  externa  is  caused  by  the  aspcrgillus 
fungus.  Mycosis  aspcri^iirnui  (Schwarize,  A\"reden,  Siebenmann), 
in  which  the  epithelial  debris  is  siutkled  with  Asf^rr^illiis  jiiticr  or 
Fu»iii^atus  fliivus,  the  existence  of  w  liicli  is  show  n  h\  iis  black'  and 
vellow  spotted  appearance.  This  form  of  otitis  is  consequent,  if 
not  necessarily,  at  least  frec|uentlv,  upon  dwelling  in  damp, 
mouldv  apartments,  and  the  growth  of  the  aspergillus  in  the  ear 
is,  according  to  Siebenmann,  combined  with  dermatitis  (for 
instance,  moist  eczema  of  the  external  ear),  or  otitis  media,  which 
discharges  serum  under  the  same  conditions  as  those  in  which 
scrofulosis  is  found.  Thus  its  etiology  has  been  connected  with 
scrofulosis. 

In  tuberculo-scrofulous  middle  ear  affections,  which  are  only 
a  small  percentage  of  the  total  of  such  complaints,  a  feeling  of 
stuffiness  in  the  ears  occurs  hrst,  then  subjective  sensations  of 
hearing,  and  now  and  then  considerable  deafness.  On  the  other 
hand,  there  is  no  pain,  or  it  is  onh'  very  slight,  so  long  as  it  is  a 
purely  tuberculous  process  with  A\]iicli  we  have  to  do;  only  with 
mixed  infection  is  there  violent  pain  (Moos),  and  at  the  same  time 
swiftly  advancing  disorganization.  Painlessness,  as  well  as  the 
existence  of  mulii|ole  perforations  in  the  membrana  t\mpani  and 
speedy  destruction  of  the  mucous  membrane  of  the  wall  of  the 
inner  tympanic  cavity  (Jacobson),  must  lead  to  suspicion  of  tuber- 
culosis, which  is  to  be  confirmed  b\'  the  demonstration  of  bacilli. 
In  tuberculosis  the  defects  in  the  tympanum  are  generally  great, 
and  the  perforations  last  a  long  time. 

As  serious  consequent  phenomena  Ave  must  note  caseous 
degeneration  of  the  mucous  membrane,  caries,  vm]  exfoliation 
of  the  ear  bones,  caries,  and  necrosis  of  the  adjacent  parts  of  bone 
of  the  mastoid  process,  formation  of  fistula  on  this  )')rocess, 
destruction  of  the  pyramid,  breaking  through  into  the  skull  cavity, 
tuberculous  meningitis,  brain  abscess,  thrombosis  of  the  petrosal 
sinus,  destruction  of  the  Fallopian  canal,  paralysis  of  the  facial 
nerve,  erosir)n  of  the  carotid. 


SYMPTOMS  1(J(J 


EYE. 


On  (lie  eyelids  we  fre(jiMiii  1\  liixi  redness,  a  discharging 
eczema  with  formation  of  criisis;  ilns  pmccss  exiends  along  the 
edge  of  the  lids,  wliich  become  red,  ihii  kciu-d,  .-ind  peel  off  in 
scales  (blepharitis) ;  the  lids  arc  found  id  adhere  on  awaking,  being 
closed  with  a  crust,  ulcers  are  fcMined,  tiie  lashes  stick  together, 
and  at  last  fall  out.  When  the  eczema  is  of  hjng  duration 
the  edges  of  the  lids  beconKj;  nodular,  hare,  and  (;ften  eciropic. 
Styes  (hordeola)  are  frequent,  and  appear  (|iii(kly  one  aftf-r  the 
other. 

By  a  continuous  transmissi(jn  of  the  process  from  the  eyelids 
or  nose,  or  in  consequence  of  direct  infection  by  dirty  hands,  or 
maybe  another  catarrlial  or  eczematous  spot,  the  conjunctiva  also 
becomes  affected.  It  becomes  red,  fleshy  and  puffy,  and  a  quantity 
of  muco-purulent  secretion  is  formed  (scrofulous  blenorrhcea), 
which  flows  together  with  the  lachrymal  fluid  down  to  the  cheeks, 
and  can  there  induce  eczema.  On  the  conjunctival  sclera  towards 
the  corneal  margin  we  see  injected  vascular  tissue,  circumscribed 
pustulous  swellings  (conjunctivitis  phlyctenulosa),  the  pustules 
burst,  discharge  their  opaque  contents,  and  give  rise  to  slight  loss 
of  substance. 

On  the  cornea  inflammation,  and  especially  phl}rienular 
processes  take  place  (keratitis  phlyctenulosa);  small  infiltrations 
on  their  disintegration  leave  shallow  ulcers,  upon  the  healing  of 
which  severe  cicatricial  opacities  and  patches  occur  often  connected 
with  fresh  vascular  formation  (pannus  phlyctenulosus),  consequent 
conditions  which  often  impair  the  evesight  and  even  lead  to 
blindness. 

These  aft'ections  are  generallv  associated  with  severe  irri- 
tation, great  dislike  to  light,  and  reflex  closing  of  the  lids; 
"  children  go  to  the  darkest  corners  and  burv  their  heads  in  a 
cushion." 

Now  and  then  g"reyish-\ellow  infiltrations  appear,  which 
afterwards  suppurate,  and  mav  lead  to  the  formation  of  hvpopion, 
perforating  ulcers,  prolapsus  iridis,  svnechia,  &c. 

Keratitis  fasciculosa  occurs  as  an  infiltration  advancing  ro  the 
centre  of  the  cornea,  which  later  induces  a  band  composed  of 
vessels  lying  closely  against  one  another. 

Phlyctenje  (which  also  appear  in  healthv  persons)  are  distin- 
guished in  the  scrofulous  by  great  frequencv,  obstinacv,  serious 
consequences,  relapse  and  photophobia  of  a  high  degree  in  propor- 
tion to  the  small  local  changes.  (For  the  bacterial  conditions, 
see  p.  13). 


200  SCROFULOSIS 

C)pinions  differ  aboui  phlyclenie  as  one  of  ihe  earliest  and 
most  frequent  symptoms  of  scrofulosis. 

Czernv  considers  it  a  symptom  of  exudative  diathesis  which 
often  heals  by  dieting  (see  Schiilz  and  Videcky),  but  llayshi  has 
demonstrated  histologically  tubercles  with  central  caseation,  in 
cases  in  which  he  could  not  succeed  in  pro\ing  bacilli,  and  which 
in  experiments  on  animals  gave  negative  results.  The  frequent 
coincidence  with  bone  and  joint  tuberculosis,  positive  tuberculin 
reaction  (Stephenson  and  Jamieson,  &c.),  the  appearance  of 
phlycteuc'e  after  the  cutaneous  test,  and  the  successful  treatment 
with  tuberculin  in  many  cases  (Schiilz  and  V^ideckv)  pt)int  to  its 
tuberculous  origin,  at  least  in  some  of  the  cases. 

Weekers  found  phlyctenas  in  91  per  cent,  of  persons  giving  a 
positive  V.  Pirquet  reaction,  in  patients  with  other  eye  diseases 
II  per  cent.  Igersheimer  demonstrated  positive  cutaneous 
reaction  in  70  per  cent,  of  children  suffering  from  phlyctena^. 

Bruno  produced  phenomena  similar  to  phlycten^e  by  injecting 
sterilized  tubercle  bacilli  into  the  vascular  system  of  rabbits. 
Cohn  and  Uhthoft"  consider  that  tuberculosis  may  be  suspected  in 
those  suffering  from  phlyctense,  especially  adults,  when  they  have 
never  before  suffered  from  the  eyes. 

In  less  severe  forms  of  scrofulosis,  inflammation  of  the  eyes, 
affections  of  the  corneal  margin,  and  eczema  of  the  skin  which 
frequently  accompanies  it,  the  superficial  position  of  the  eruption, 
the  fact  of  its  being  easilv  influenced  by  external  agencies  and  the 
more  frequent  proof  of  pathogenic  bacteria,  when  compared  with 
other  affections,  all  point  to  external  infection. 

Staub  considers  that  severe,  obstinate  and  recurring  scrofu- 
lous ophthalmia  is  a  paratuberculous  expression  of  latent  bronchial 
tuberculous  glands,  in  the  sense  given  by  Neumann,  an  opinion 
which  may  doubtless  be  correct  for  many  cases.  Scrofulous 
ophthalmia  is  frequentlv  only  a  secondary  symptom  of  suppura- 
tion in  the  nose  (its  neighbouring  cavities  and  the  naso-pharynx), 
and  ceases  spontaneously  when  these  are  cured  (Rothholz,  &c.). 

Affections  of  the  bones,  the  non-tuberculous  nature  of  which 
is  only  indicated  by  the  lack  of  everv  other  tuberculous  symptom, 
are  speciallv  observed  at  the  orbital  margin  of  the  lachrymal  bone. 
The  external  symptoms  are  cedema  of  the  lids,  chemosis,  pro- 
trusion of  the  bulb,  and  in  the  further  course  loss  of  mobility, 
abscess  formation  and  rupture  catising  disfiguring  ectropion. 
(For  further  information,  see  vol.  xxi,  ch.  iv,  pp.  403-406.) 

Trachoma  has  been  stated  to  be  connected  with  scrofula. 
True,  on  the  ground  of  his  experience,  even  believes  that  granules 
are  in  most  cases  onlv  absorbed  by  scrofulous  patients,  and  onlv 


SYMPTOMS  20 1 

in  such  cases  unlold  llicir  lull  cllccl,  vvliiisi  in  jic-ililiv  jjersons 
no  complications  ai)])<';ii-.  ()ili(*r  writers  (S(liniifii,  Kimplfr) 
associate  severe  conse(|uences  when  scrofulosis  is  combinfd  with 
trachoma. 

The  clinical  |)ictur(;  of  lr;i<li(»nia  ma\-  Ix-  iuiilaicd  in  tulj'-r- 
culosis  of  the  sclerotic  and  tiil)fr(  iil<  ms  follicK-s  on  the  conjunctival 
fold  (Rheim,  Bongarlz,  Bach  .mil   I  l(,'inersdf)rff). 

We  cannot  properly  asccri.i in  how  often  the  tuberculous  form 
of  scrofulosis  is  accompanied  by  specific  tuberculous  rhan/:(es  or 
similar  changes  in  the  eye.  Thus  parenchymatous  keratitis,  which 
is  sometimes  observed  in  scrofulosis,  may  be  of  a  tuberculous 
nature  (Bongarlz,  Michel).  'I'he  formalir)n  of  tubercles  in  the 
conjunctiva,  partly  in  the  form  (A  lupus,  has  been  observed  at 
times  (see  'Cornet,  "  Die  Tuberculose,"  second  edition,  p.  332, 
and  the  classification  of  Amiet,  Burnet,  and  Denig). 

The  tuberculous  nature  of  chalazion  has  often  been  demon- 
strated (H.  Wagner,  Eangl),  but  it  would  be  going  too  far  to 
consider  chalazion  in  every  case,  or  even  generallv,  to  be  tuber- 
culous. 

SYMPTOMS  IN  THE  OTHER  MUCOUS  MEMBRANES. 

Catarrh  of  the  deeper  respiratory  passages — trachea  and 
bronchi — are  more  remarkable  in  scrofulous  people  by  their 
obstinacy  than  by  their  frequenc\". 

Intestinal  catarrh  is  frequentlv  put  down  to  scrofulosis. 

The  opinion  of  Escherich,  Sec,  that  in  scrofulo-tuberculosis 
catarrh  may  partly  be  traced  to  the  discharge  of  tuberculo  toxin 
may  perhaps  be  justified,  though  it  has  not  been  proved. 

We  often  find  in  scrofulous  girls,  even  in  childhood,  catarrh 
of  the  vaginal  mucous  membrane  with  abundant  discharge  of  a 
muco-purulent  secretion  (fluor  albus).  A  large  number  of  these 
cases  in  which  the  gonococcus  may  be  demonstrated  depend  on 
gonorrhoeal  infection  by  stuprum  or  other  occurrences,  and  do 
not  come  under  consideration  here.  At  other  times  tubercle 
bacilli  are  found  (Demme),  whilst  a  considerable  proportion  of 
cases  depend  on  pus  cocci  (and  not  on  specific  infection)  which 
have  been  accidentalh'  introduced  by  "  cleansing  "  with  dirtv 
cloths,  by  intentional  irritation,  or  other  accidental  circumstances 
by  the  children  themselves  or  other  persons.  Xaturallv  such 
catarrh  happens  with  girls  who  are  otherwise  healthy,  as  intensive 
irritation  mav  open  a  point  of  entrv  for  bacteria  even  in  the 
densest  epithelium,  only  then  thev  disappear  more  quickly  than 
in  scrofulous  children. 


202  SCROFULOSIS 

C— SYMPTOMS   IN  THE   LYMPH   GLANDS. 

After  the  scrofulous  symptoms  ai  the  point  of  entry,  affections 
of  the  lymph  glands  are  the  most  important  to  be  considered. 

The.  tuberculous  and  pyogenic  forms  generally  produce  the 
same  symptoms  at  the  beginning,  only  as  a  rule,  in  the  ]->y(igenic 
form,  if  virulent  germs  be  the  cause,  the  course  is  somewhat  more 
speedy.  A  stationary  condition  for  a  long  period  and  caseation 
are  symptoms  which  are  often  found  only  in  tuberculous  glands. 

NECK  GLANDS. 

Affections  of  the  neck  glands  are  prominent  on  account  of 
their  superficial  position  and  their  frequency,  especially  the  sub- 
maxillary, sub-auricular,  and  cervical  glands. 

The  gland  becomes  harder,  and  swells  so  that  it  can  be  easily 
felt,  and  grows  to  the  size  of  a  pea,  bean,  hazel  nut,  or  pigeon's 

egg. 

The  swelling  takes  place  slowly  and  imperceptibly  without 
complications,  and  often  without  sensible  pressure  symptoms. 
On  this  account  for  a  long  time  they  are  not  noticed  by  the  patient, 
and  are  only  discovered  accidentally.  The  skin  over  the  glands 
is  unchanged,  can  be  easily  moved  and  raised  in  folds.  The 
gland  remains  without  any  particular  changes  for  a  long  time,  in 
this  condition  it  can,  especially  when  not  of  a  tuberculous  nature 
or  the  bacilli  are  avirulent,  return  spontaneously  to  a  healthy 
condition,  that  is,  if  the  affection  arising  from  the  source  of 
infection  (pro\-ided  such  had  been  discovered)  heal,  and  so  the 
supply  of  toxin  and  toxic  matter  ceases.  It  will,  however,  persist, 
although  the  original  affection  mav  be  long  healed. 

In  the  meanwhile  the  neighbouring  glands  swell,  and  a  chain 
like  a  row  of  beads,  which  is  palpable  and  even  visible,  appears, 
the  parts  of  which  grow  into  large  tumours  with  a  nodular  surface. 
From  fresh  inflammatory  processes  in  the  zone  from  which  the 
affection  arises  or  from  unknown  causes,  softening  and  suppura- 
tion of  the  glands  supervene,  they  adhere  to  their  surroundings 
by  periadenitic  processes,  lose  their  mobility,  and  surround  the 
anterior  part  of  th.e  neck  as  a  lump}-  mass  the  size  of  an  egg.  At 
times  they  penetrate  the  soft  tissues  and  the  space  between  the 
auditory  meatus,  the  mastoid  process,  and  the  posterior  margin 
of  the  lower  jaw,  and  may  cause  pressure  on  the  carotids,  the 
jugular  vein,  air  passages,  pharynx,  and  upper  part  of  the 
oesophagus,  and  lead  to  cerebral  congestion  and  to  pain. 

The  fluctuation  in  the  softened  glands  extends  to  the  sur- 
rounding parts,  the  skin  over  them  adheres,  becomes  doutrhv  or 


SYMJ'TOMS  203 

ocdcmaloiis,  slrcLclicd,  .slimy  .'ind  -  r.-i<ln,'ill  \  iliiniKT.  Ai  las'., 
unless  clicckcd  l)y  operalinn,  one,  or  more  oficn  sf\fral,  small 
openin<;s  appear,  (Jiil  ol  wliirli  a  ])urulenL  or  watery  lluid  resem- 
blino-  sour  milk  and  caseous  Ira/^nnenls  dischar^^e.  'j'lie  fistula- 
which  [u'lve  formed  enlarge  to  ulcers  with  underminerl  flaccid 
margins,  :\\m\  sometimes  lead  lo  a  sinuous  cavitv  tilled  with 
spongv  granulations  which  have  been  formed  from  a  ihickened 
capsule  of  the  gland.  They  greatly  retard  healing;  it  is  only 
after  complete  discharge  of  all  caseous  matter  and  dead  remains 
of  gland  tissue  that  the  secretion  dries  up,  and  a  bright  red.  srtme- 
times  deeply-sunk  scar  is  formed. 

The  process  drags  on  for  months  and  years,  and  continues 
longer  if  more  glands  which  have  in  the  meanwhile  become 
affected  soften  and  suppurate.  Now  and  again  deep  subcutaneous 
abscesses  form  which  penetrate  towards  the  jugular  and  the  supra- 
clavicular fossae. 

INGUINAL  AND  AXILLARY  GLANDS. 

Similar  phenomena  appear  when  the  inguinal  or  axillary 
glands  take  part  in  the  scrofulous  process. 

Scrofulous  inguinal  and  axillary  glands  suppurate  in  general 
more  rarely  than  the  neck  glands  ;  they  often  remain  of  moderate 
size  when  they  swell,  for  example,  owing  to  neighbouring  bone 
affections.  The  difference  may  be  owing  to  the  opportunity  for 
pyogenic  mixed  infections  being  present  much  more  rarely  than 
in  the  head,  where  the  frequent  skin  aiTections,  such  as  eczema, 
&c.,  afford  a  point  of  entry  for  them. 

Whilst  affections  of  the  neck,  and  the  more  rarely  attacked 
inruinal  and  axillarv  o-lands,  run  their  course  before  our  eves  or 
are  at  least  easily  found  bv  palpating,  aiTections  of  the  internal 
glands  (in  the  chest  and  abdomen)  betray  their  presence  only 
indirectly,  and  are  only  to  be  discovered  by  complicated  methods 
of  examination.  Although  they  appear  not  to  come  much  into 
evidence,  they  play  (at  least  in  the  tuberculous  form)  a  far  more 
important  part. 

BRONCHIAL  GLANDS. 

It  was  only  at  the  end  of  the  century  before  last  and  at  the 
beginning  of  the  following  that  more  attention  was  paid  to  the 
bronchial  glands.  Lalouette,  Becker,  then  later  Barthez  and 
Rilliet,  Gueneau  de  Mussy,  Barety,  "Widerhofer,  Ouain,  <&:c., 
advanced  our  knowledge  bv  detailed  researches  on  the  symptom- 
atology and  pathology  of  these  glands. 

They    are    not    to    be    reached    by    palpation ;    at   most    their 


204  SCROFULOSIS 

presence  is  indicated  by  a  chain  of  glands  extending  into  the 
adiaceni  region  of  the  neck,  or  now  and  again  their  presence  is 
rendered  probable  by  an  increased  feeling  of  resistance  in  the 
infraclavicular  region.  When  ihey  become  of  large  size  they 
prevent  the  expansion  of  the  thorax,  antl  nia\'  cause  a  constant 
throwing  back  of  the  head  (Xeumann).  The  principal  symptoms 
which  point  to  affection  of  the  bronchial  glands  are  caused 
mechanically  by  pressure  of  the  glands,  which  gratlually  increase 
in  size,  on  the  organs  in  tiieir  vicinity. 

Subjectivelv  a  feeling  of  heaviness,  of  pressure  on  the 
sternum,  an  oppression  "  as  if  there  were  a  lump  in  the  chest  " 
sometimes  direct  pain  near  the  seat  of  the  disease  is  experienced. 
There  may  be  also  pain  between  the  shoulder-blades,  great 
sensitiveness  to  pressure  on  the  sternum  and  the  \ertebral  column, 
especiallv  on  the  spinous  processes  from  the  second  to  the  seventh 
dorsal  vertebra?.  At  the  same  time  in  the  beginning  there  is  often 
a  cough  which  can  be  explained  by  no  other  physical  phenomena. 

Even  with  slight  increase  in  the  size  of  the  enlarged  gland 
symptoms  of  pressure  on  the  nerves  are  noticed.  One  of  the  vagi 
or  its  branches  becomes  compressed  (as  was  known  by  Wrisberg), 
and  owing  to  this  the  pulse  is  quickened,  either  persistenth'  or 
intermittently. 

The  quickened  pulse,  which  many  authors  mention  as  the 
precursor  of  phthisis,  may,  in  mv  opinion,  have  its  cause  in  such 
a  swelling  of  the  bronchial  gland. 

Occasionallv  palpitation  of  the  heart  or  abnormal  beating  of 
the  heart  (Nagel,  &c.)  and  irregular  pulse  may  appear  in  conse- 
quence of  pressure  on  the  arteries. 

In  this  wav  even  dilatation  of  the  heart  and  death  may  occur. 
The  compression  of  sensitive  branches  of  a  vagus  nerve  can  lower 
the  reflex  activity  of  the  tracheal  or  bronchial  mucous  membrane 
or  increase  the  dif^cultv  of  removing  an\'  inspired  germs  or  the 
normal  secretion,  and  facilitate  infection  by  favouring  catarrh. 
In  the  last  of  these  circumstances  we  may  see  the  reason  for  the 
frequent  appearance  of  pulmonarx'  tulierculosis  after  certain 
infectious  maladies,  such  as  measles.  See. 

Variot  mentions  paroxvsms  of  pain  in  tlie  cardiac  region 
three  or  four  times  and  oftener  in  the  dav  quite  without  cause  (and 
often  appearing  in  a  manner  reminding  one  -of  angina  pectoris) 
which  lasted  an  hour,  and  which  was  combined  w  i(h  a  long  fit  of 
hacking  coughing,  probablv  caused  bv  compression  and  stimula- 
tion of  the  vagus  nerve,  perhaps  of  the  cardiac  plextis. 

By  pressure  on  the  recurrent  nerve  or  its  particularlv  irritable 
bifurcation,  a  convulsive  cough  coming  on  in  short  fits,  dry  and 


SYMFTOMS  205 

often  very  liarsli,  is  pnuliK  cd,  \cr\  much  like  w  liooping-coiigli, 
and  it  may  even  be  aiicmicd  1)\  Noniiiing.  (^ften  fits  of  dyspnoea 
and  fits  res(;mblin:y  .-isiliin;!  ;iif  exhibited  with  frf-rjuenl  change  of 
symptoms  (Barthez  and  Killiet,  1  lerard,  &c.). 

With  ])aralysis  (jf  th(;  recurrent  nerve  paresis  of  the  laryngeal 
muscles  supplied  b\  ii  appears,  generally  on  one  side,  and  on  tjie 
left  side,  owing  to  tiie  deeper  course  of  the  nerve;  in  consequence 
there  is  hoarseness  and  aphonia;  exceptionally  paresis  occurs  on 
both  sides. 

"One  can  see  the  ciiild  crying,  but  cannot  hear  ii,"  says 
Berghinz,  of  a  case  in  which  both  recurrent  nerves  were  embedded 
in  the  bronchial  glands  which  were  the  size  of  an  orange.  Further, 
there  may  be  difficulty  of  breathing,  laryngeal  spasms  ''in  r.ne  case 
of  Ander's  even  death). 

The  pupil  of  the  affected  side  can  become  enlarged  by  involve- 
ment of  the  sympathetic  nerve. 

Pressure  on  the  trachea  and  bronchi,  which  on  account  of 
their  tirmness  give  way  with  difficulty,  is  follow-ed  by  contraction 
of  the  lumen.  It  declares  itself  by  a  gurgling  noise  during 
expiration,  and  often  at  the  end  of  inspiration  by  an  increased 
frequency  of  respiration,  by  a  gulping  noise  in  coughing,  by 
dyspnoea  mostly  of  an  inspiratory  nature,  with  stridor,  especially 
during  excitement  and  movement,  often  increased  by  the  horizontal 
position,  and  in  the  highest  stage  amounting  to  orthopnnea. 

Under  the  influence  of  dyspnoea  a  rhythmical  drawing  in  of 
the  lower  aperture  of  the  thorax  may  take  place  in  the  form  of  a 
deep  channel  in  the  situation  of  the  false  ribs  (Guinon). 

By  pressure  the  oesophagus  is  put  out  of  its  position,  and  at 
times  dysphagia  supervenes. 

By  pressure  on  the  arch  of  the  aorta  hypertrophy  of  the  heart 
mav  be  induced  ;  by  compression  of  the  superior  vena  cava  cedema 
in  the  face,  in  the  neck,  or  in  one  or  both  arms — the  cachectic 
osdema  of  phthisical  patients  begins  in  the  lower  extremities — 
cyanosis  of  the  face  and  lips  similar  to  that  in  afifections  of  the 
heart,  distension  of  the  veins  of  the  neck  and  chest  (Grober, 
Allan,  &c.),  are  symptoms  which,  however,  appear  but  seldom ; 
there  is  inclination  to  bleeding-  at  the  nose,  which  has  a  bad 
significance  as  an  apparent  precursor  of  phthisis,  giddiness, 
somnolence,  bleeding  from  the  arachnoid  membrane,  according 
to  some  authors  salivation  ;  these  symptoms  are  very  valuable, 
especially  when  they  occur  on  one  side  only. 

Pressure  on  the  pulmonary  veins  causes  hypera?mia,  con- 
gestion, rales,  and  eventually  spitting  of  blood. 

I  would  also  mention  inspiratory  lowering  of  the  pulse  bv 


2O0  SCROFLLOSIS 

pressure  on  ilie  aoria,  and  ilit-  briiiL  in  ihe  veins  w  hen  bending  the 
head  far  back  owing  lo  compression  ot  the  innominate  vein 
(Goguel). 

For  changes  in  ihe  ph\sical  condition  caused  l)y  swelling  of 
the  glands,  see  Diagnosis  (p.  242). 

W'e  musfespeciallv  emphasize  the  extraordinary  variation  and 
the  intermittent  character  of  the  functional  and  physical  symptoms 
of  many  swellings  of  the  bronchial  glands.  They  exacerbate 
suddenlv  and  disappear  very  cjuickly,  influenced  by  slight,  often 
unknown  causes,  atmospheric  pressure,  and  dampness  of  the  air 
(J.  Simon). 

The  swollen  bronchial  glands  apparently  remain  a  very  long 
time  in  the  same  condition.  They  become  most  intimately  con- 
nected with  neighbouring  parts  and  surround  them  on  all  sides. 
Kven  the  pleuraj  and  pericardium  may  be  sympathetically  affected 
by  the  spread  of  the  inflammatory  processes  in  the  glands  or  by 
the  action  of  transuded  toxin. 

The  glandular  swelling,  after  existing  for  a  long  period  and 
after  several  remissions  and  exacerbations,  may  retrograde,  and 
may  heal  with  shrinking  and  calciflcation.  Or  the  glands  may 
become  soft,  especially  under  the  influence  of  pyogenic  bacteria, 
suppurate  and  burst  through  if  their  surroundings  allow  them  to 
do  so.  If  they  burst  into  a  bronchus  or  the  trachea  the  purulent 
caseous  matter  is  coughed  up,  and  may  infect  the  respiratory 
passages  by  suddenly  closing  the  bronchi ;  they  induce  severe 
d\spna"a  and  frequenllv  cause  death. 

Meynet,  and  Poland  (who  reports  a  case  of  bursting  at  the 
same  time  into  the  oesophagus),  Tait,  Lundis,  Wallis,  Loeb 
(Literature),  Gulliver,  Biggs,  Rolleston,  Comba  have  described 
the  bursting  through  the  trachea  and  the  large  bronchi. 

The  bursting  through  is,  as  a  rule,  preceded  for  a  long  lime 
by  difficulty  of  breathing,  asthmatic  symptoms  and  stridor  caused 
by  the  protrusion  of  the  tumour  into  the  wall  of  the  trachea,  where 
Polak  in  one  case  observed  it  with  the  tracheoscope. 

Sometimes  with  children  who  are  apparently  healthy  sudden 
violent  cough  and  severe  dyspnoea  will  occur,  and  in  one  such  case 
of  Dina's,  tracheotomy  was  resorted  lo  on  accouni  of  suspected 
diphtheria,  after  w^hich,  during  a  severe  fit  of  coughing,  a  caseated 
gland  was  brought  up.  Sometimes  after  the  first  attack  of 
dyspnoea  an  improvement  will  be  observed,  then  a  renewed  attack 
followed  by  perforation. 

The  caseated  mass  may  entirely  fill  up  the  lumen  of  the 
trachea  and  lead  to  death  from  suffocation,  as  in  a  case  of  Reunert, 
Koch  and  others. 


SYMI'IOMS  207 

In  a  case  of  I N'lciscn's,  life  was  prf*.sf;rvf;d  by  a  speedily 
[)(;rtonnc(l  I  i-.-iclicolomy  (s(m;  also  I*' ran/,  Polak  and  Lolirer). 
l{ni[)li vscnia  ol  llic  skin  may  also  arise  from  a  nipinrc  inlo  the 
bronchi  (lienda). 

A  nipliiiv-  inid  ihe  vessels,  [)cili,-ips  lollowcfl  b\-  miliary 
tuberculosis,  (jccurs  less  easily,  because  ihesc;,  ha\in^^  a  less  rigid 
wall,  can  more  easily  yield  and  avoid  adhesions.  iJillricli  men- 
tions a  case  where  a  casealcd  gland  sfiilcd  on  die  ascending  aorta 
and  grew  into  il.  W'e  ha\-e  many  records  of  cases  in  which 
perforation  into  the  u'sophagus  or  a  bronchus,  and  simultaneously 
int(^  a  \-essel,  look  |)lace  and  there  caused  fatal  bk-cding 
(Okonomides,  Kidd,  Michael,  R.-iiifenberg,  Harry  (in  a  woman 
aged  71),  Widerhofer). 

Now  and  theti  only  small  \essels  will  l^e  eroded  by  a  gland 
communicating  with  a  bronchus,  and  then  give  rise  to  a  perplexing 
form  of  hcemoptosis  in  healthy  lungs. 

Perforation  into  the  oesophagus  seldom  takes  place. 
Weichselbaum,  I5eck  and  Zenker  have  each  published  a  case, 
with  consequent  tuberculosis  of  the  oesophagus ;  the  three  cases 
were  all  in  elderly  persons,  or  at  least  adults. 

Further  cases  of  bursting  through  the  oesophagus  are  supplied 
by  Xeurnann,  Poland  (in  a  child  aged  ij),  Hanot  (in  a  person 
aged  22),  Selenkow  (in  a  person  aged  50),  Volker  (in  a  bov 
aged  7),  Meyerhoff  (trachea  and  oesophagus).  Scarred,  retracted, 
glandular  diverticula  can  form  in  the  oesophagus  owing  to  the 
strain. 

Irruption  into  the  pleura,  pericardium,  mediastinum  often 
induces  pleurisy,  pyopneumothorax,  or  pericarditis.  In  Koch's 
case  perforation  into  the  pericardium  was  followed  bv  a  strepto- 
coccic sepsis. 

According  to  illustrative  cases,  as  far  as  thev  are  confirmed 
by  post-mortem  examination,  the  severe  symptoms  that  arise 
depend,  as  a  rule,  on  tuberculous  or  tuberculo-pyogenic  causes 
(mixed  infection),  naturally  distinct  from  other  malignant  growths, 
such  as  sarcomatous  degenerations.  Less  severe  chronic  but 
transitory  swelling  of  the  bronchial  glands  occur,  as  it  seems, 
more  frequently  than  we  are  accustomed  to  think  is  the  case,  for 
example,  in  connection  with  bronchitis,  &c.,  and  these  svmptoms 
are  often  erroneously  put  down  to  the  primar\'  disease. 

MESENTERIC  GLANDS. 

The  mesenteric  glands,  which  frequentlv  exhibit  inflammatorv 
swellings  even  in  simple  intestinal  affections,  cause  few  character- 
istic symptoms  in  scrofulous  inflarnmation,  which  is  mostlv  of  a 
tuberculous  nature.     But  they  extend,   especially  when  they  do 


208  SCROFULOSIS 

not  caseaie  or  calcify,  over  a  very  wide  range,  and  can  be  felt 
as  thickened,  hard,  uneven  masses  through  the  sofi,  yielding 
abdominal  wall,  generally  near  the  na\el,  though  the  absence  of 
palpable  tumours  does  not  pro\e  thai  ihe\-  do  not  exist.  Henoch 
mentions,  for  instance,  that  in  a  girl  ageel  5  the  Uibercuk»us  mass 
oi  mesenteric  glands,  accompanied  by  simuhanei.ius  chronic 
peritonitis,  coukl  not  he  detected  by  palpation,  ahhough,  as  the 
post-mortem  proved,  the  mass  was  the  size  of  a  child's  liead. 
\\'hen  mesenteric  scrofula  (tabes  mesenlerica)  has  been  of  long- 
duration  the  abdomen  is  generally  distended  and  bulky,  which  is 
rendered  more  perceptil)le  by  the  thinness  of  the  body.  Some- 
times it  is  accompanied  bv  swelling  of  the  inguinal  glands. 

Frecjuenilx-  ilicse  niescnieric  scrofulous  patients  suffer  from 
indigestion,  often  accompanied  by  obstinate  diarrhcx?a,  as  well  as 
from  more  or  less  violent  intercurrent  abdominal  pains;  these  are 
often  the  only  symptoms,  lasting  weeks  and  months,  and  some- 
times leading  to  a  fixed  position  with  the  legs  drawn  up. 

Now  and  then  spasmodic  attacks  of  pain,  accompanied  by 
fever  and  \omiting,  appear  (Fromm),  and,  exceptionally,  cramp  in 
the  calves;  the  loose  connection  in  which  the  mesenteric  glands 
stand  to  the  abdominal  organs  allows  of  a  reciprocal  yielding,  and 
thus  extensive  groups  of  hmphatic  glands  may  be  present  without 
giving  rise  to  symptoms  of  pressure,  as  is  the  case  with  the 
bronchial  glands.  The  course  is  often  run  without  s\'mptoms, 
for  example,  a  child  of  seven  with  advanced  tuberculosis  of  the 
mesenteric  glands  only  experienced  abdominal  pains,  followed  by 
vomiting  with  fever  and  delirium,  five  days  before  death  (Etsches). 

At  times  they  compress  the  trunks  of  the  vessels,  by  which, 
distension  of  the  abdominal  veins  and  even  oedema  of  the  lower 
extremities  may  be  induced. 

The  glands  ma}-  heal  and  disappear,  or  calcify  by  absorption 
of  lime  salts.  Sometimes  they  grow  into  the  walls  of  the 
intestines,  soften  and  perforate  either  into  the  lumen  of  the 
intestines  of  the  peritoneal  cavitv,  so  gi\-ing  rise  to  peritonitis. 
But  we  may  have  peritoneal  irritation  and  exudation  (perhaps  in 
consequence  of  transuded  bacterial  toxin)  without  perforation. 
Extension  into  the  mesenteric  artery  has  also  been  observed  (see 

pp.    221-222). 

The  considerable  disturbances  of  metabolism  which  accom- 
pany scrofulosis  of  a  tuberculous  nature  lead  to  severe  wasting, 
which  has  given  rise  to  the  name  tabes,  or  phthisis  mesenterica; 
in  severe  cases  the  further  consequences  of  cachexia  are  induced, 
such  as  amyloid  degeneration  of  the  alDdominal  organs,  swelling 
of  the  feet,  &c. 


SYMPTOMS  2()(j 

D.     SYMPTOMS  OF   BONE   AND  JOINT  AFFECTIONS. 

AITcclions  of  llie  bones  and  join  is  [jnsnppo.sf;  a  lo(  us  already 
existing  in  llie  body  (see  p.  145). 

We  have  to  do,  as  a  rnle,  uiili  ilif  iiil)cr(  iilons  form  vvliieli 
nahirally  appears  independenlly  ol  scrolnlosis  in  iIm-  liain  of 
liibereiilosis  of  other  organs. 

Scrofulosis  of  the  bone  exliibils  ilscji  esjx'f  iailv  at  thi' 
epiphysis  of  the  long  bones,  in  iIk;  spongy  niechillary  tissue  of  the 
end  of  (he  joints,  and  more  rarely  at  (he  diaj)liysis;  in  (he  siu^rl 
bones,  the  phalang(\s  of  the  fingers  and  loes,  and  oecasionallv  in 
the  radius,  ulna,  and  libula  (in  young  persons).  Generally  about 
the  lifth  year  a  central  inllanimalion  l^egins  in  the  medulla  of  the 
affected  bone — spina  venlosa — which  is  recognized  externally  as 
a  distension  and  spindle-shaped  bulging. 

The  chronic  course  is  accounted  for  by  the  near  relati(.n  of 
the  spongy  tissue  to  the  lymph  glands. 

For  the  relative  frequency  in  each  bone,  see  p.  135. 

A  detailed  discussion  of  the  symptoms  does  not  lie  within 
the  scope  of  this  book.  I  refer  my  readers  to  the  surgical  manuals 
dealing  with  them,  and  confine  myself  here  to  a  short  sketch. 

Foci  in  the  bones  often  remain  localized  for  years.  At  times 
pain  is  felt,  which  becomes  worse  at  night  and  shoots  into  the 
neighbouring  parts,  at  other  times  the  pain  may  disappear  or 
increase  in  intensity  (for  example,  when  there  is  discharge  into 
the  joint);  it  may  confine  the  patient  to  bed,  and  when  continuing 
for  a  long  period,  with  no  perceptible  changes  in  tlie  joints,  lead 
one  to  suspect  a  neurosis. 

In  the  further  course  the  affected  limb  becomes  limited  in  its 
movements,  a  feeling  of  weakness  is  experienced,  and  the  part 
becomes  stiff  and  easily  tired.  In  affection  of  the  vertebral  column 
the  trunk  and  head  are  often  held  in  unnatural  positions  to  take 
the  weight  from  the  spine,  and  to  avoid  pain  the  child  grasps 
chairs  and  other  objects,  and  later  places  both  hands  on  the  thighs, 
a  position  which  is  typical  of  the  affection.  The  stiffness  of  the 
back  is  especially  noticeable  on  attempting  to  pick  up  objects  off 
the  floor. 

,With  the  growth  of  the  focus  in  the  bone  reactive  changes 
appear  in  the  periosteum,  such  as  thickening,  which  is  recognized 
on  superficial  bones  by  a  doughy  feeling,  and  bv  the  pressure  of 
the  finger  leaving  an  indentation.  At  first  the  skin  is  normal, 
later  often  tense  over  the  affected  part  of  the  bone,  continual  pain 
and  sensitiveness  to  pressure  are  felt ;  these  are  often  confined  to 


2IO  SCROFULOSIS 

certain  points  of  the  epiphysis,  and  are  then  oi  great  importance 
diagnostically  ;  they  may  be  accompanied  by  slight  remittent  fever. 
Wiien  the  site  is  superficial  a  less  clear  sound  is  emitted  in 
percussion  with  the  pleximeler  over  such  aflecicd  si:)ongy  bones 
(I.iicke). 

Cold  abscesses  are  formed  on  the  l)one,  and  fistulas  with 
granulations  at  the  margin,  which  lead  tlow  n  to  the  carious  bone 
and  which  heal  with  difficulty.  The  joint  is  often  considerably 
afl'ected  s\-mpathelicall\-,  without  extension  through  ruplin-e 
having  taken  place  in  it,  clearly  owing  to  transuded  toxins. 

The  foci  in  the  bone  have  often  attained  considerable  dimen- 
sions before  extension  into  the  joint  takes  place. 

This  extension  into  the  capsule,  or  through  the  cartilage 
into  the  joint,  may  take  place  with  acute  and  often  violent  pain, 
accompanied  by  external  signs  of  inflammation,  or  it  may  take  a 
chronic  course;  in  this  case  the  pain  is  absent  often  for  a  long 
period,  in  spite  of  considerable  joint  changes,  or  is  only  felt  when 
there  is  a  weight  on  the  joint  or  when  it  is  over-exerted.  It  is 
often  discovered  by  the  child  crying  out  at  night,  and  this  may 
be  the  first  sign  of  incipient  spondvlilis  or  coxitis.  Later,  jiain  is 
felt  on  palpation,  especiallv  at  certain  points  (fixed  pain  points). 

The  pains  spread  through  pressure  on  the  nerves,  and  express 
themselves  by  spondylitis  in  certain  regions  according  as  the  part 
concerned  is  the  vertebral  column,  the  occiput,  neck,  shoulder  and 
arms,  the  whole  back,  the  region  of  the  kidneys,  or  as  a  painful 
feeling  of  constriction  in  the  breast  or  abdomen.  Recently  such 
a  case  was  brought  before  me  which  for  a  long  time  had  been 
treated  as  an  affection  of  the  kidneys.  The  pains  extend  to  the 
legs  or  pass  into  the  sternal  region.  Later,  by  the  sinking  in  of 
the  affected  vertebral  curve,  affection  of  the  bladder,  paralysis  of 
the  arms,  or  spastic  paraplegia  of  the  legs  appears.  In  coxitis 
pain  may  be  felt  for  months  in  a  healthy  knee,  and  give  rise  to 
unpleasant  mistakes  as  to  the  seat  of  the  malady. 

Tn  other  cases  of  joint  affections  disturbances  of  the  power  of 
motion  take  place  at  an  early  stage.  At  first  there  is  only  a  certain 
stiffness  and  awkwardness,  especially  on  rising  in  the  morning 
or  at  any  beginning  of  movement;  the  limb  exhibits  a  certain 
weakness,  the  patient  loses  his  certainty  in  walking,  and  is 
inclined  to  fall.  Such  a  fall  is  erroneously  considered  the  traumatic 
beginning  of  bone  tuberculosis,  which,  as  a  fact,  was  already 
present. 

The  coxitis  shows  itself  often  weeks  and  months  before  th. 
appearance  of  pain  by  slight  limping  and  dragging  of  the  leg, 
spondylitis  by  stiff   position    of   the  vertebral  column,    the   child 


SYMI'TOMS  211 

being  (|iiil('  lively  vvilli  il.  Awk'vv.'ird  [xtsii  ions  aiKJ  muscular 
conlrael ions  are  formed.  Tlic  pali'-ni  seeks  lo  lix  ihe  joinl  in  (lie 
most  conv(Miienl  antl  painless  manner.  In  (oxjiis  iIm-  ihigli  is 
flexed,  abducled  and  rolaled  onlwaids,  laier  Hexed,  addueied  and 
rotated  inwards.  In  joinl  fungus  ilie  knee  is  lield  in  a  lialf-bent 
position,  whilst  in  an  elbow-joint  fungus  il  lak(;s  llie  middle  posi- 
tion, between  pronation  and  supinalion;  uilli  straigliKming  or 
further  movement  the  pain  is  often  alle\ialed.  An  apparent  or 
real  lengthening  or  shortening  of  a  limb  lakes  place;  when  f:om- 
plelely  undressed,  one  sees  that  in  walking  llie  paliimt  lays  the 
weight  on  ihe  heailliy  side  and  sloops  towards  llie  healthy  side. 
Walking  becomes  more  diriicult  ;  sometimes  the  limb  becomes 
entirely  fixed.  Ilip-joinI  alfeclions  are  accomjianied  l)\'  painful 
twitching  of  ihe  muscles,  especially  at  night. 

In  a  number  of  cases  the  first  s\mptom  is  a  change  of  shape 
in  the  affected  joint,  a  swelling,  either  due  lo  peri-articular  pro- 
cesses (tumour  albus),  or  to  granulations  in  the  joint  itself.  The 
buttocks  become  flat,  the  gluteal  fold  disappears,  the  knee  becomes 
spherical,  the  elbow  spindle-shaped.  The  swelling  becomes  more 
marked  as  the  affected  limb  becomes  atrophied  al)ove  and  below 
the  joint  (muscle  alropln-).  Fluctuation  and  crepitus  are 
frequently  met  with,  especially  in  certain  positions. 

Owing  to  disease  in  the  bone  and  relaxation  of  the  capsule 
spontaneous  luxation  and  subluxation  arises. 

Frequently  the  Avell-known  cold  abscesses  form,  usually  insidi- 
ously. Sometimes  they  are  the  first  of  the  svmptoms,  in  other 
cases  they  are  entirely  absent.  Their  size  varies  extremelv  and 
independently  of  the  extent  of  the  bone  lesion,  from  a  few  drops 
to  several  litres  of  pus.  They  are  often  far  ad\anced  before  thev 
become  noticeable,  and  parti v  owing  to  the  law  of  gravitation, 
but  also,  doubtless  influenced  by  the  contraction  of  the  muscles, 
they  sink  towards  the  side  where  they  find  the  least  resistance, 
where  the  connective  tissue  is  the  loosest,  or  along  the  course  of 
the  vessels  and  nerves  (hence  the  name  wandering  abscess) 
(Hueter). 

From  the  dorsal  part  of  the  vertebral  column  thev  sink  towards 
the  pelvis,  along  the  psoas  muscle,  and  appear  on  the  inner  side 
of  the  thigh,  or  they  travel  from  the  shoulder-joint  along  the  long 
head  of  the  biceps  to  the  upper  and  posterior  end  of  the  deltoid, 
or,  starting  from  the  hip-joint,  in  front  of  and  on  the  outside  of 
the  tensor  fascia  lata?,  appear  again  in  the  gluteal  region  or  in 
the  pelvis. 

If  such  a  wandering  abscess  burst  or  be  incised  it  discharges 
a  crumblv,  caseous,  sometimes  thin,  pus  resemblino-  whev.  which 


212  SCROFI'I-OSIS 

is  distinguished  hv  its  while  c-i>lour  from  ihe  yellow-greenish  pus 
of  phlegmonous  foci. 

Now  and  again,  though  seldom  in  children,  a  tuberculous 
hydrops  forms,  usually  chronic,  with  exacerbation  and  remission 
of  the  discharge,  seldom  acute.  The  joint  is  painful,  swells,  the 
skin  becomes  red,  the  temperature  of  the  body  rises,  and  the 
discharge  flows  within  a  few  hours  in  a  patient  apparently  healthy 
(latent  tuberculosis).  The  hydrops  may  again  disappear,  leaving 
a  thickened  capsule. 

In  other  but  rarer  cases  suppuration  takes  place  inside  the 
joint  (cold  abscess  of  the  joint),  followed  by  fluctuation  and  burst- 
ing. Or  mixed  infection  shows  itself,  especially  when  an  external 
wound  exists;  severe  septic  processes  may  then  increase  the  whole 
symptom  complex. 

Often  there  is  not  onlv  one  bcMie  or  joint  lesion  ;  several  are 
formed,  even  four,  five,  or  more,  sometimes  shortly  after  one 
another,  sometimes  at  an  interval  of  years. 

Bone  and  joint  affections  may  run  their  course  without  any 
considerable  disturbance  or  fever,  yet  when  the  process  is  further 
advanced  fever  of  a  remittent  character  usually  appears  (hectic 
fever  of  Konig)  with  low  sub-febrile  morning  and  evening  tem- 
perature, but  rising  to  38°  to  39°  due  to  a  chill.  I  wish  here  to 
emphasize  that  for  earlv  and  exact  knowledge  of  the  fever  it  is 
necessary  to  take  the  temperature  every  two  hours. 

All  the  affections  described  are  mostly  chronic,  seldom  acute. 
They  mav  exacerbate,  remit,  often  be  at  a  standstill  for  a  long 
period,  and  may  even  after  a  long  time  definitely  and  spontane- 
ously heal.  Abscesses  may  be  again  absorbed  and  disappear,  the 
pain  may  be  reduced,  the  swelling  go  down,  the  secretion  from 
fistulc'e  dry  up,  the  fistul^e  close,  the  muscles  become  strong,  and 
the  affected  limb  regains  entirelv  or  in  part,  according  to  the  degree 
of  disturbance,  its  former  mobilitv.  In  other  cases  bony  or  con- 
nective tissue  ankyloses  may  remain  (curvature  of  the  spine.  Potts' 
curvature,  kyphosis). 

Such  places  are,  on  account  of  the  changed  conditions  of 
circulation,  specially  adapted,  when  isolated  bacilli  at  some  time 
or  other  enter  the  blood  and  lymphatic  vessels,  to  retain  them, 
and  to  reinaugurate  the  previous  processes.  Therefore  recur- 
rences must  bv  no  means  depend  on  reanimation  of  a  few  living 
bacilli,  which  have  remained  in  the  healed  lesion,  as  many 
authors  suppose,  but  it  mav  just  as  well  be  traced  to  a  new  batch 
or  fresh  infection. 

If  healing  does  not  take  place  the  tedious  processes  exhaust 
ihe  bodv  and  lead  slowlv  to  amvloid  defeneration  of  the  kidneys 


SYMI'KhVIS  ^1.^ 

(albiiminiii  i;i),  ol  ilic  li\cr  ,-iih1  spleen  (enlargciiieni  ;iii(l  li/nden- 
ing),  and  ol  iIh;  inlesline  (profuse  diarrJid'a),  to  genenil  dropsy 
and  dt'.'illi.  ( )r  bacilli  are  sel  free,  cnicr  ilie  blf)f)d  passages,  and 
induce  according  lo  circunislances  eillier  miliary  tuberculosis  or 
local  tuberculosis  in  the  brain,  in  oilier  bony  parts,  ike,  and  so 
bring  the  existence  of  the  individual  to  a  speedy  end.  Now  and 
again  surgical  trealmeni  has  had  fatal  consequences,  although 
extensive  operation  (res(>ction  with  complete  elimination  of  tlie 
diseased  parts)  has  been  relatively  more  successful  than  small 
operations  on  the  diseased  tissue,  such  as  scraping  with  a  sharp 
spoon,  &c. 

E.— GENERAL  SYMPTOMS. 

Atnaemia. — Owing  to  the  long  continuation  of  the  scrofulous 
processes  and  tlie  continual  absorpticjn  of  poisonous  substances, 
the  blood  and  the  body  generally  is  included  to  a  certain  degree 
in  the  aflfection,  as  we  have  already  partly  hinted  at  above.  We 
often  observe  a  high  degree  of  anaemia  in  the  scrofulous  in  the 
further  course  of  the  disease. 

Monti  and  Berggriin  found  in  a  boy  of  about  6,  who  was 
suffering  from  tuberculous  glands,  38  per  cent,  of  haemoglobin 
and  3,640,000  red  corpuscles  and  14,000  white  corpuscles.  Elze 
also  noticed  in  scrofulosis  that  there  is  generally  a  reduction  of 
haemoglobin  and  red  corpuscles,  and  the  former  appeared  to  be 
more  altered  than  the  latter.  Besides  which,  Elze,  in  eight  cases 
of  scrofulosis,  instead  of  the  normal  proportion  of  white  and  red 
corpuscles,  i  : 500-800  for  adults,  found  proportions  of  i  :ii  or 
97  or  480,  but  we  must  take  into  consideration  that  the  blood  of 
young  children  is  richer  in  white  corpuscles,  and,  according  to 
Gundobin,  their  relative  number  is  about  three  times  as  large 
as  in  adults.  Becker  notes  the  increase  of  lymphocytes  in  the 
scrofulous.  The  generally  reduced  number  of  eosinophiles  in 
the  tuberculous  increases  apparently  when  the  process  takes  -^ 
favourable  turn.  In  surgical  tuberculosis  in  children  the  eosino- 
philes were  constantly  found  to  be  increased,  and  in  inverse  ratio 
to  the  severity  of  the  affection.  See  also  Rubino,  Lanza,  and 
others,  and  p.  54. 

■  Fever. — Slight  feverish  attacks  appear  frequently,  at  least 
in  the  tuberculous  form,  which,  on  account  of  the  rarity  with 
which  the  temperature  is  usually  taken,  are  easilv  overlooked 
(see  "  Die  Tuberculose,"  second  edition,  p.  727).  The  fever  as 
a  rule  is  only  slight,  because  in  consequence  of  the  occlusion  by 
the  capsules  of  the  glands  the  production  and  absorption  of  the 
toxins  is  on  the  whole  less  than,  for  instance,  from  a  tuberculous 


2  14  SCROFULOSIS 

lung  focus  which  is  in  connection  witli  the  lynipli  vessels  and 
lymph  spaces  in  its  whole  periphery ;  the  more  extensive  the 
tui)ercuious  lesions  are  ilie  more  frequently  and  the  higher  the 
temperature  rises.  \\'ith  plentiful  absorption  of  toxin,  as  in 
caseated  bone  and  joint  lesions,  hstula,  retained  pus,  &.C.,  hectic 
fever  is  reached,  often  with  perspiration. 

The  anatomical  structure  of  the  gland  also  encourages  the 
pvogenic  form,  but  the  important  quality  of  the  tubercle  bacillus, 
nameU',  ilu-  jiowcr  of  protlucing  iliromliosis  in  the  \"cssels  and 
thus  reslriciing  the  dispersal  of  the  toxin,  is  wanling  (see  p.  126, 
and  "  Die  'i\il)erculose,"  second  edition,  p.  ()Sj).  The  appear- 
ance of  fexer  depends  al)o\e  all  on  the  greater  or  less  \  irulence 
and  toxic  effect  of  the  pus  bacteria  in  cjueslion. 

Of  earlier  writers,  Ilufeland  has  devoted  a  special  chapter 
to  fever  in  the  scrofulous,  and  Virchow  has  spoken  of  the 
tendencv  to  febrile  conditions,  recalling  the  febricula  of  phthisical 
patients,  whilst  most  aiuhors,  with  the  exception  of  Birch-IIirsch- 
feld,  hardlv  mention  the  word  fe\er.  H.  Neumann  has  recentl}-, 
and  perfectl}-  rightly,  mentioned  the  frequency  of  fever  tempera- 
tures, even  if  onlv  slight  o7'7°  ^'>  o^'3°  (in  the  rectum),  which  he 
found  in  62  per  cent,  of  his  scrofulous  patients,  and  emphasizes 
it  as  an  important  symptom  under  certain  circumstances,  an 
opinion  with  which  1  entirely  concur  from  my  own  experience. 
More  attention  should  be  paid  to  the  frequent  "cold  shivers" 
in  the  morning  and  e\"ening  and  not  just  put  it  dow  n  to  aniemia. 

It  is  often  only  a  slight  rise  of  temperature,  once  daily  to 
37"2°  to  37'3° — axillary  temperature — only  to  be  recognized  by 
taking  it  every  two  hours,  whicli  indicates  tuberculosis  of  the 
bronchial  and  mesenteric  glands  (see  Diagnosis,  p.  237). 

I  should  mention  that  Ludke  and  Sturm,  S.  Chaldier  and 
Poncet,  Reyher,  and  (;thers,  demonstrated  orthostatic  albuminuria 
in  tuberculous  or  scrofulous  patients,  and  Re\her  sujDposes  a 
direct  causal  connection  between  (he  two.  Lemoine  found  it  also 
in  five  soldiers  with  all  the  signs  of  inherited  tuberculosis.  See 
also  Benati  and  Max  Wolf. 

Nourishment. — The  longer  and  more  severe  the  disease,  the 
more,  as  a  rule,  the  general  nutrition  of  a  scrofulous  patient 
suffers.  It  exhibits  itself  chieih-.  in  spite  of  excessive  hunger, 
now  and  then  in  those  suffering  from  mesenteric  scrofulosis,  as 
well  as  in  long-continued  bone  and  joint  suppuration.  Frequently, 
however,  the  appetite  is  diminished. 

Fenwick  notes  a  special  form  of  scrofulous  dvspepsia  which 
he  observed  42  times  in  2,000  cases,  and  whicli  he  considered 
a  neurosis  of  the  intestine.     Quite  suddenly,  in  the  middle  of  the 


SYMl'TOMS  215 

nighl  oi'  iininc(|i;ilciy  ;i.llci"  .-1  iih-;iI,  ihcic  isp;iiii  in  Mi'-  .'ibfloincD, 
vvliicli  (Ik-  [)a,ti('nL  tiincics  is  in  iIk;  region  oi  lin;  nuvcl,  tin;  pain 
begins  al)()V(-  iL  and  Lo  lh(;  right,  llicn  extends  to  the  left  as  well, 
and  has  a  boring  character;  it  lasts  from  five  minutes  to  several 
hours,  and  is  relieved  by  pressure.  Tlie  stools  are  constipated, 
colourless,  offensive,  and  slimy,  and  contain  a  quantity  of 
unchanged  matter.  Need  for  evacuaticm  comes  on  at  meal-times, 
often  after  the  first  mouthful,  nausea  and  vomiting  are  rare.  The 
general  health  is  ccjnsiderably  upset. 

In  the  nervous  system,  besides  the  feeling  of  being  easily 
tired  at  play  or  work,  and  (jccasional  sleeplessness,  a  certain 
irritation  and  instability  of  temper  is  observed  in  many  scrofulous 
persons. 

The  amyloid  degeneration — which  we  have  already  men- 
tioned as  a  consequence  of  protracted  bone  and  joint  suppuration 
— may  also  make  its  appearance  in  the  course  of  suppuration  of 
the  glands  only. 

F.— THE  SCROFULOUS  CONSTITUTION. 

A  malady  which  lasts  so  long,  and  is  connected  with  manifold 
disturbances,  naturally  stamps  the  body  externally  with  a  distinct 
mark  of  disease. 

As  long  as  scrofulosis  was  traced  back  to  dyscrasia  dominating 
the  whole  body,  the  scrofulous  constitution,  the  general  bodily 
peculiarities  which  are  so  often  observed  in  the  scrofulous  were 
considered  precursors  of  the  disease  which  doomed  the  individual 
to  scrofulosis. 

Even  a  certain  lack  of  harmony  of  the  external  form  was 
put  down  by  Lugol  and  others  to  scrofulous  constitution,  either 
"  the  limbs  were  too  long  or  too  short,"  "  the  body  too  small  or 
disproportionally  large,"  "  the  mouth  small  or  much  too  large," 
"  the  appetite  too  small  or  voracious."  As  perfect  harmony  in 
the  body  is  a  rarity,  it  would  not  be  difficult  to  demonstrate  one 
of  these  defects  in  every  scrofulous  person  as  a  sign  of  a  scrofulous 
constitution. 

In  contradiction  to  Lugol's  statement,  that  every  scrofulous 
child  was  weakly,  and  that  scrofulosis  excluded  the  attributes  of 
strength  and  health,  Louis  has  cast  doubts  on  the  predominating 
influence  of  constitution,  and  Lebert  has  questioned  the  criterion 
of  a  weakly  constitution.  The  latter  believes  that  unprejudiced 
observation  has  given  us  no  right  to  look  upon  a  weak  constitu- 
tion as  predisposing  to  scrofulosis,  for  the  experience  which 
apparently  supports  it  was  traced  back  to  one-sided  opportunities 
of   observation   in   a   children's   hospital   and   on   poor   children. 


2l6  SCROKULOSlS 

\irclu)w  and  others  note  ihc  aiijii-arance  oi  scrolulosis  in  children 
otherwise  healthy. 

Tlie  fact  that  scrofulosis,  like  lubcrculosis,  ot'ien  heals  in  one 
organ  such  as  the  glands,  and  in  ant)iher,  sucii  as  ilie  bones,  con- 
tinues its  course,  while  in  ihc  same  organ  ii  will  heal  in  one 
place  and  extend  in  another,  is  incompatible  with  such  a  general 
dyscrasia  as  a  preliminary  condition,  also  with  the  acceptance  of 
a  general  diathesis. 

A  strikingly  perceptible  sign  of  scrofulous  constitution  was 
believed  to  have  been  found  in  the  scrofulous  liahitus,  a  sign 
which  was  highly  valued  at  the  end  of  the  century  before  last 
and  the  beginning  of  last  century.  Two  primary  forms  were 
distinguished,  the  erethistic  and  the  torpid  hahiius. 

The  erethistic  form  is  characterized  by  a  slim  build,  weak, 
wasted  musculature;  little  adipose  tissue,  a  soft,  tender,  pale  skin, 
easilv  becoming  red,  the  veins  are  visible  as  a  network  of  bluish 
colour,  bright  moist  eyes  with  wide  pupils,  silky  soft  hair,  blue- 
white  well-polished  teeth,  an  intelligent,  active  mind,  a  lively 
temperament  but  easily  depressed,  and  often  an  early-developed 
sexual  instinct.  Many  authors  see  further  signs  in  fair  hair  and 
blue  eyes  (Birch-IIirschfeld),  others  in  dark  hair,  long  dark 
lashes  and  dark  eyes  (Henoch).  These  are  for  the  fair  sex,  those 
phenomena  of  ephemeral  beauty  which  the  artist  describes  as 
"  beaute  du  diable,"  and  the  country  folk,  as  an  apple  "with 
a  maggot  at  the  core." 

The  torpid  type  is  characterized  by  a  heavy  build,  puffy 
condition  of  body,  pasty  appearance,  podgy  limbs,  with  a  quantity 
of  spongy,  adipose  tissue,  but  without  strong  musculature,  short 
thick  neck,  large  head,  pale  complexion,  unusually  strong  massive 
jaw  bone,  a  swollen,  thick  broad  nose,  thick  puffy  upper  lip, 
stupid  expression,  with  signs  of  mental  dulness  and  arrested 
development,  phlegmatic  temperament,  dislike  to  bodily  exercise, 
and,  according  to  some,  having  fair  hair  and  blue  eyes  (see  above). 

As  the  greater  part  of  the  scrofulous  could  not,  even  with 
the  best  possible  desire,  be  classed  under  either  of  these  two 
heads,  a  third  or  "  middle  type  "  was  introduced. 

Critical  observation  shows  us  that  the  scrofulous  plu-siognomy 
exhibits  itself  in  a  great  number  of  the  scrofulous,  not  as  a 
condition  of  body  preceding  scrofulosis,  but,  as  Virchow  has 
already  noted,  as  an  expression  of  disease  already  existing.  The 
clinician,  Lebert,  who  only  found  this  habitus  8i  times  amongst 
537  scrofulous  patients,  rightly  remarks  that  "  it  is  much  less 
seldom  found  if  the  habitus  be  noted  before  the  diagnosis,"  in 
other  words,  when  the  judgment  is  not  prejudiced. 


SYMl'lOMS  217 

Of  all  these  so-called  premonilory  symptoms,  tlie  line  skin 
might  give  us  a  certain  clue,  liui,  iiniortunaiely,  by  combining 
too  many  symptoms  tiie  woiili  and  iniporiance  of  singl<;  symplf^ns 
have  been  effaced.  As  for  the  rest  of  the  signs  oi  the  scrolulous 
habitus,  one  can  easily  understand  that  with  extensive  swelling 
of  the  glands,  a  compressi(jn  (jf  the  vessels,  and  coiisccjiniiily  a 
blockage  of  lymph  may  be  induced,  which  causes  a  change  in  the 
outward  appearance  of  the  patient,  and  cxijlains  the  puify  face, 
&c.  It  is  just  as  readily  understood  lliai  s( mlnlosis  is  more 
distributed  amongst  the  po(jrer  classes,  because  of  tlieir  crowded 
dwellings,  witii  increased  opportunities  of  infecticjn,  the  conse- 
quences of  poverty,  Bad  dwelling  houses  and  bad  nt^urishment ; 
also  a  pale  complexion  and  defective  bodily  development  must  be 
oftener  found  without  there  being  necessarily  a  causative  con- 
nection with  scrofulosis. 

Scrofulosis,  especially  when  of  long  duration  and  higli  degree, 
has  an  effect  on  the  bodily  and  mental  powers.  Children  exhibit 
a  dishke  to  exercise  and  do  not  join  their  comrades  in  games 
which  require  bodily  movement,  they  often  complain  of  weariness, 
even  on  rising  in  the  morning,  and  tliey  hold  tliemselves  badlv, 
wiiich  is  accounted  for  by  weakness  of  the  spinal  muscles.  Instead 
of  racing  about  like  other  children,  they  sit  down  quietly,  even 
when  not  forced  to  do  so,  by  reason  of  the  type  of  their  malad}' — 
bone  and  joint  disease — and  prefer  to  read  or  to  give  themselves 
up  to  the  pictures  of  their  imagination. 

Soltmann,  in  his  further  statements  respecting  his  theories 
already  laid  down,  traces  the  production  of  the  erethistic  and  torpid 
habitus  to  the  concentration  and  effects  of  the  chemical  changes 
and  products  of  the  tubercle  bacilli  on  the  blood  and  lymph 
systems.  Czerny  contests  the  connection  of  a  scrofulous  habitus 
with  tuberculous  infection,  and  looks  upon  it  principally  as  the 
expression  of  the  exudative  diathesis  which  might  be  made  to 
disappear  by  dieting  with  food  containing  little  fat  and  no  eggs 
or  milk.  But  the  habitus  may  be  influenced  and  nullified  by 
tuberculin  treatment  without  change  of  diet  (Escherich,  Heubner. 
and  others).  It  is  clear  that  there  are  more  factors  which  work 
together  as  causes. 

This,  as  well  as  the  more  frequent  association  of  weakly 
children  with  older  persons,  instead  of  with  companions  of  their 
own  age,  explains  the  advanced  mental  development,  a  certain 
precociousness,  which  we  And  in  such  children,  and  a  more  grave 
demeanour,  which,  if  the  disease  runs  a  favourable  course,  is  often 
retained  during  the  whole  life. 


2lS  SCROFULOSIS 

On  ihc  other  hand,  with  many  children  the  mental  develop- 
ment is  retarded  by  certain  forms  of  scrofulosis,  and  this  is  often 
observed  as  a  consequence  of  adenoid  growths.  Doubtless  owing 
to  the  blocking  of  the  lymph  passages,  which  in  brain  and  nose 
are  connected,  the  children  have  difficulty  in  concentrating  their 
altenlion  t)n  any  object  (Gu}e's  aprosexia,  Bresgen,  and  Seller). 
On  this  account  they  give  cause  for  constant  complaints  from 
school  and  fall  behind  in  ilicii'  .sUKlies,  unless  steps  are  tak?n 
in  time. 

riu'  taci  was  noied  frequenth',  esi)eciall\'  b\'  older  writers, 
thai  in  the  scrofulous  the  development  of  the  sexual  organs  was 
often  considerablv  later  than  in  the  normal.  I  have  not  remarked 
whether  this  is  frequently  the  case,  but  in  scrofulous  girls  men- 
struation appears  in  general  later  than  in  the  healthy  of  the  same 
generation,  also  troubles  in  menstruation  are  more  frequent. 

An  imusually  early  awakening  of  the  sexual  instincts  is 
mentioned  bv  some  authors  (Baumes),  by  others  exactly  the 
opposite  is  stated. 


SKCTION    IV. 

Course  and   Duration   o5   the 
Disease. 


ScROFULOsis  alnKjst  always  runs  a  chronic  c(jurse,  willi  many 
exacerbations  and  remissions;  it  is  only  really  comparatively  acute 
in  tiie  tuberculous  form,  perhaps  owing  to  multiple  infection. 
Tiie  course  is  determined  by  the  number  and  species  of  the  germs 
which  have  entered,  Ihe  intensity  of  their  proliferation  and  dis- 
persal, by  the  organs  attacked  and  by  the  anatomical  peculiarities 
of  tiie  individual. 

We  may  in  general  distinguish  four  stages  of  scrofulosis  :  — 
(i)  Superficial  infection  of  skin  and  mucous  membranes. 

(2)  Affections  of  the  glands. 

(3)  Bone  and  joint  affections. 

(4)  The  various  terminations,  including  amyloid  disease. 
The    single    stages    play    a    more    or    less    important    part 

according  to  the  form  of  the  scrofulosis.  In  the  pyogenous  we 
meet,  as  a  rule,  with  only  the  first  two,  in  the  tuberculous 
principally  witli  the  last  three.  By  tlie  simultaneous  existence 
of  various  stages  and  of  both  forms  many  combinations  arise. 

The  superficial  phenomena  of  the  pyogenous  form  belong  in 
general  to  the  first  years  of  childhood  and  the  crawling  age. 

A.— COURSE  OF  PYOGENOUS  SCROFULOSIS. 

In  the  pyogenous  form  of  scrofulosis  the  local  svmptonis  are 
most  marked  at  the  point  of  entry,  in  tlie  skin  and  mucous  mem- 
branes, such  as  eczema,  catarrh,  &c.,  for  the  above-mentioned 
reasons.  The  symptoms  will  often  be  confined  to  the  same  place 
for  a  considerable  time,  or  tliey  repeat  themselves  constantlv, 
or  appear  now  in  one  place,  now  in  another,  in  continual  changes. 

The  affections  may  remain  localized  at  the  point  of  entry 
and  the  glands  be  affected  only  in  this  way,  so  that  the  diffusible 
poisons  of  the  bacteria  arrive  at  that  point  from  the  tributary 
area;   irritation  follows,   with  consequent  swelling,  inflammatory 


220  SCROFULOSIS 

li)  pi-rplasia,  and  e\en  suppuraiiun.  ihesc  clianges  in  tlie 
glands,  as  well  as  the  attection  of  the  tributary  area,  are  chronic; 
if  the  disease  heal  and  the  supply  from  the  area  traversed  by  the 
lymph  passages  meeting  in  that  gland  be  thus  cut  off,  then  the 
changes  in  the  glands  disappear  in  a  short  time  (scrofula  fugax). 

If  bacteria  enter  even  into  the  glands  and  set  up  independent 
processes,  these  may  continue  an  indeiinite  time  without  suppura- 
tion after  the  healing  of  the  surrounding  zone,  on  account  of  the 
generallv  slight  virulence  of  the  bacleria  in  question,  and  at 
last  may  retrograde.  If  highly  virulent  bacteria  enter  at  the 
beginning  or  later,  acute  suppurating  processes,  abscess  forma- 
tion and  rupture  occur. 

We  see  different  combinations ;  the  skin  affections  may  be 
healed  yet  the  glands  remain  swollen,  or  the  glands  may  be 
healing  when  a  new  process  establishes  itself  in  the  area,  or  the 
glands  of  one  part  are  healthy  and  the  respective  tributary  area 
connected  with  that  gland  is  diseased,  or  another  region  diseased 
and  the  area  in  connection  with  it  healthy,  and  so  on,  with  a 
multiplicity  of  variations. 

The  glands  form  a  more  dependable  cover  for  pyogenous 
bacteria  than  for  tubercle  bacilli,  perhaps  on  account  of  their  size, 
perhaps  from  other  causes.  A  dissemination  from  the  glands 
to  the  bones  or  other  organs,  the  third  stage,  is,  to  say  the  least, 
one  of  the  most  extraordinarily  rare  occurrences;  still,  the  possi- 
bility should  not  be  denied. 

The  disturbances  in  the  general  health  are  unimportant,  both 
an  account  of  the  slight  spread  of  the  process  into  the  interior  of 
the  body,  and  because  of  the  less  toxic  characters  of  the  bacteria, 
so  that  we  may  rightly  term  the  disease  a  mild  scrofulosis. 

B.— COURSE  OF  TUBERCULOUS  SCROFULOSIS. 

As  regards  the  course  of  tuberculous  infection,  the  slower  or 
quicker  advance  of  the  processes,  and  the  possibility  of  spon- 
taneous retrogression,  it  is  very  important  which  type  of  bacillus, 
whether  human  or  bovine,  has  caused  the  infection.  For  the 
present  too  few  researches  have  been  made  in  this  connection 
to  enable  us  to  state  the  course  precisely.  The  differences  are 
apparently  of  a  more  gradual  type  (see  Prognosis,  p.  228) ;  the 
general  direction  of  the  course  remains  the  same. 

First  Stage. —  In  the  tuberculous  form,  as  a  rule,  we  rarely 
find  svmptoms  at  the  point  of  entry.  The  child's  mucous  mem- 
branes are  easily  penetrated  by  isolated  bacilli,  therefore  the  first 
stage,  if  the  infection  take  place  in  them,  is  generally  left  out. 
In  the  skin  the  bacilli,  if  they  have  been  able  to  penetrate,  are 
retained  on  the  spot  by  the  firmer  tissue  and  often  so  completely 


COIJRSK    AND    1)1   KA'IION    Ol'     I  1 1 1'.    DISKASK  221 

that  no  second  stage  is  reached.  Lupus  may  cxisi  for  a  lonj,^ 
liiTK!  without  the  nearest  glanrls  being  affected. 

These  siipciricial  .•ilTccl  ions  nrc  generally  extraordinarily 
(dironic. 

Ilaike,  on  the  oilier  hand,  notes  the  sometimes  extremely 
rapid  course  of  tuberculous  ear  affections  in  infants.  Thus,  in 
a  child  5  weeks  old,  a  few  days  after  suppuration  had  set  in, 
facial  paresis  was  observed,  and  at  the  post-mortem,  which  took 
place  three  weeks  later,  the  whole  of  the  temporal  bone  and  the 
kibyrinth  showed  tuberculous  changes.  Acute  miliary  tuber- 
culosis can,  with  exacerbation,  lead  to  death  in  twenty-four  hours 
with  high  fever  rmd  coma  (T^npowski).  The  natural  path  for  the 
dispersal  of  (he  process  from  the  s]<in  and  mucous  membranes 
is  by  way  of  the  lymph  passages  to  the  lymph  glands,  which 
apparently  always  offer  a  transitory  hindrance  to  the  bacilli  an-| 
so  forms  the  second  stage  (see  p.  122). 

The  brain  may  be  infected  directly  by  the  nasal  mucous 
membrane  without  the  intervention  of  the  glands  on  account  of 
the  connection  of  the  lymph  vessels  on  both  sides,  so  that  in 
such  a  case  death  from  meningeal  tuberculosis  follows  immedi- 
ately on  the  first  stage.  In  rare  exceptional  cases  direct  infection 
of  the  underlying  bones  may  take  place  from  the  skin  and  mucous 
membranes  through  the  lymph  paths — third  stage  added  to  the  first. 

Second  Stage. — Affections  of  the  glands  form  the  recognized 
second  stage  of  scrofulosis.  We  see  this  stage  most  plainly  in 
the  neck  glands.  As  a  rule  the  disease  advances  but  slowly,  as 
the  retention  of -the  bacterial  poison  and  also  the  quantity  of  lymph 
cells  hinder  the  development  of  the  bacilli  (see  p.  125).  If  the 
bronchial  or  mesenteric  glands  are  affected  the  second  stage  is 
often  latent  for  a  long  period.  With  continued  absorption  of  the 
bacterial  poison  a  general  weakness  comes  on  insidiouslv  as  a 
want  of  tone  of  the  whole  organism,  or  appears  onlv  in  connection 
with  other  diseases,  such  as  measles,  scarlet  fever,  &c* 

Tuberculo-scrofulous  glands  of  even  considerable  extent  mav 
retrograde  even  after  a  duration  of  months,  and  the  processes  of 
the  disease  heal  completelv  if  no  extension  to  other  glands  or 
organs  has  taken  place. 

We  have  seen  in  cattle  that  glands  which  have  been  affected 
by  human  bacilli  which  are  foreign  to  them,  and  which  have 
attained  to  the  size  of  a  hen's  egg  or  goose's  egg,  retrograde  to  a 
calcareous  focus  the  size  of  a  peppercorn,  therefore  it  is  not 
remarkable  if  in  children  the  changes  caused  bv  the  bovine 
bacillus,  which  is  almost  foreign  to  them,  again  disappear  entirely 
or  are  reduced  to  chalky  foci. 

But  usually  the  gland  softens  sooner  or  later,  spontaneouslv 


22  2  SCROFl'LOSIS 

or  aided  by  accidenlal  bacteria,  li  biirsis,  t\>rnis  a  fisiula  or  an 
ulcer  which  secretes  for  months  and  years,  and  only  heals  after 
shedding  all  gangrenous  tissue,  often  leaxing  a  disfiguring  scar. 

In  the  meanwhile  the  protective  and  liltering  power  of  the 
glands  becomes  insulTicient,  either  on  account  of  the  advanced 
process  or  under  the  influence  of  extraneous  inflammation,  such  as 
measles,  &c.,  or  trauma;  the  bacilli  spread  further,  and  the  more 
easily  the  younger  the  individual.  Owing  to  centripetal  spreading 
in  the  direction  of  the  lymph  current  chains  of  glands  are  formed, 
for  example,  from  the  neck  into  tlu^  mediastinum. 

In  the  case  observed  by  Marfan  and  Oppert,  of  a  child 
13  months  old  which  had  swelling  of  the  neck  glands  and 
"angina,"  in  a  few  days  llu-rc  was  suppiiraiidii  of  numerous 
neck  glands  with  the  formation  of  a  (|uaniii\-  n\  pus,  in  which, 
according  to  the  authors,  a  great  many  tubercle  bacilli  were 
found  as  the  only  inciters  of  the  suppuration. 

The  pressure  of  a  large  mass  of  glands  on  the  vessels,  nerves, 
trachea,  bronchi  and  oesophagus  may  give  rise  to  severe  con- 
sequences, paralysis,  dyspnoea,  dvsphagia,  rupture  into  the 
trachea,  to  pulmonarv  tuberculosis  and  suffocation  ;  rupture  into 
the  vessels  mav  cause  fatal  haemorrhage. 

Various  groups  of  glands  which  are  not  in  immediate  con- 
nection, which  do  not  lie  in  the  same  centripetal  direction,  which 
even  belong  to  different  regions  of  the  body,  for  example,  the 
bronchial  and  mesenteric  glands,  may  be  affected  simultaneously 
or  shortlv  after  each  other.  It  would  be  wrong  to  suppose  that 
the  affections  of  the  different  groups  of  glands  were,  as  a  rule 
or  of  necessity,  dependent  on  one  another.  Such  an  idea  con- 
tradicts clinical  and  experimental  work,  which  teaches  that 
tubercle  bacilli  not  only  pass  through  some  glands,  and  avoiding 
others  settle  in  the  glands  lying  nearest  in  continual  succession, 
step  by  step  and  not  by  bounds. 

The  preponderating  majority  of  such  cases  depends  doubtless 
on  multiple  external  infection.  It  cannot  be  contested  that  the 
opportunitv  for  this  infection  of  the  individual  was  given,  as 
his  disease  shows,  bv  living  in  an  environment  rich  in  bacilli. 
Whv  should  not  bacilli  at  the  same  time  or  at  intervals  be 
inspired  or  have  entered  the  mouth  or  intestines  at  some  other 
point  in  the  interior  of  the  bodv  or  on  the  external  surface  and 
have  infected  them  ? 

RETROGRADE  DISPERSAL. 

ExceptinnalK',  single  bacilli  become  detached  from  a  gland 
lesion  by  compression,  or  some  other  obstacle,  and  are  turned 
from  their  direct  centripetal   direction  and   drawn   into  collateral 


COUKSIO    AND    DIKAIION    Ol'     I  1 1 1-;    DISIIASK  22.3 

and  cvv.u  r(;lurnin_L;-  hraiK  lies,  .-iiul  (-illifr  nloiu-  or  in  cmnpany  with 
migratory  cells  cnlcr  llic  ^dands  vvhi*  h  li<'  al  ihc  side  <>v  in  iIm' 
opposite  direclion  ol   llic  Ivmpli  (  iiiiimiI  . 

'I'liose  cases  poini  lo  (Ik-  possihiliis  nl  rci  rof^riadc  lraiislcr<-ii<  <• 
williin  die  lyini)li  passag(^s  wliirli,  in  die  case  ol  ( arcinonialous 
or  sarcomatous  degenerahon  ol  die  hronchial  glands,  also  e.xliihil 
melaslalic  cancerous  or  sarcomatous  foci  in  the  suhpleural  net- 
work of  the  lymph  vessels,  whilsl  in  ilie  inleri(»r  of  dif  lungs, 
from  which  the  cancer  in  the  lym|)h  \-essels  mighi  lia\e  grown, 
tumours  are  wanting  (Vogel). 

The  ohsei"\ahons  of  I  Idler,  who  found  'i  cancerous  ernhchis 
in  the  branches  of  the  veins  of  the  liver  in  a  case  of  carcinoma  of 
the  cav-um  which  he  had  watched,  proves  that  even  llie  venous 
blood-current,  whic-h  is  expelled  much  more  strongly,  may  take 
a  reverse  direction,  at  least  at  times  and  under  cert'dn  conditions. 
A  reverse  current  in  the  Ivmph  vessels  of  the  head  is  facilitated 
bv  the  less  development  of  the  valves  (Bonam\),  therefore  it  is 
quite  possible  that  bacilli  also  in  the  Ivmph  spaces  may  be  con- 
ducted further  in  a  reverse  direction.* 

In  my  experiments  with  animals  I  have  several  times  been 
in  a  position  to  observe  an  undoubted  reverse  infection  of  the 
glands.  Tn  infection  from  one  side  of  the  navel,  besides  tuber- 
culosis of  the  inguinal  glands,  1  have  even  been  able  to  demon- 
strate now  and  then  caseation  of  the  further  Iving  peripheral  skin 
glands,  but  this  happened  only  once  in  about  4,000  cases  which 
were  always  thoroughly  examined  for  this  very  condition  of 
glands,  and  that  in  animals  which  generallv  exhibit  extraordinarv 
facility  for  the  dispersal  of  bacilli  through  the  Ivmph  passages. 
At  any  rate,  it  is  not  justifiable  to  make  a  rule  of  an  exception. 
When  Neumann  supposes  for  the  greater  part  of  cases  of  scrofula 
that  the  neck  glands  are  affected  in  ascending  direction  from  the 
bronchial  glands,  this  supposition  is  entirely  without  support  from 
facts ;  it  is  just  as  if  we  should  state  the  paradox,  that  the  normal 
direction  of  the  lymph  current  is  the  reverse  direction  (see 
pp.  T22-T26). 

The  general  health  suffers  more  the  more  the  processes 
extend,  the  more  tubercle  toxin  is  absorbed,  the  more  loss  of 
substance  takes  place  from  open  lesions.  Increasing  pallor, 
lowering  of  temperature,  loss  of  strength,  betrav  the  severe 
internal  disorganization  ;  with  the  gradual  discharge  of  all  tuber- 
culous matter  the  disease  may  be  brought  to  a  standstill,  to 
healing,  the  patient  can  even  develop  into  a  completelv  strong 
long-lived  individual ;  but  usuallv  a  phvsical  inferiority  remains 

'*■  With  regard  to  this  I  would  refer  to  the  work  of  Recklinghausen, 
(See  Bibliography.) 


224  SCROFULOSIS 

for    years    or    for    ihc    whole    life       In    oiher    cases    the   general 
exhaustion  increases  and  leads  at  last  to  death. 

Besides  being  carried  into  the  nearest  lymph  glands,  the 
liacilli  which  have  been  freed  may  pass  into  the  blood  passages 
or  the  organs  of  the  body.  Tuberculous  meningitis  may  be 
induced  or  complicated  pulmonary  tuberculosis,  the  appearance 
of  which  so  dominates  the  whole  picture  that  scrofulosis  falls  into 
the  background,  or  the  bacilli  may  reach  the  kidneys,  testicles,  &c. 
But  frequently  the  bacilli  enter  the  bones  and  joints  and  so  intro- 
duce the  third  stage  of  scrofulosis. 

Third  Stage. — This  can,  it  seems,  also  appear  primarily,  the 
t'lrst  stage  being  passed  over,  the  second  (the  formation  of  gland 
foci)  not  being  demonstrated  owing  to  the  hidden  position  of  the 
bronchial  or  mesenteric  glands. 

The  general  symptoms  become  more  and  more  evident.  The 
bone  lesions  mav  burst  outwards,  forming  fistulas,  which  heal 
with  great  difficulty,  or  cold  abscesses  appear,  the  vertebra?  may 
partly  collapse,  and  Pott's  deformity  arise.  The  joint  is  attacked 
and  disturbances  of  mobility  take  place  in  varying  degrees  up  to 
complete  fixation  and  uselessness  of  the  joint. 

These  processes  may  take  years,  and  are  often  accompanied 
by  aggravation  or  improvement.  Even  with  extensive  lesions  "n 
the  bones  and  joints  a  temporary  or  permanent  standstill  is 
possible,  but  generally  with  great  loss  of  movement ;  in  spite  of 
treatment  the  disease  frequently  advances,  and  this  unfavourable 
issue  introduces  to  some  extent  the  fourth  stage. 

Fourth  Stage. — The  extensive  purulent  processes  cause 
amyloid  degeneration  of  the  abdominal  organs,  and  death  occurs 
after  gradual  exhaustion  and  oedema. 

Or  the  bacilli  are  further  disseminated,  as  in  the  former 
stages,  and  induce  brain,  lung  or  general  miliary  tuberculosis. 
It  is  usually  accidental  pulmonary  tuberculosis  which  brings  about 
with  relative  frequency  the  unfavourable  end  of  the  sufferings  in 
scrofulosis.  It  is  not  always  a  consequence  of  bone  tuberculosis, 
but  owes  its  existence  more  often  and  more  probably  to  the  same 
focus  as  bone  tuberculosis,  namely,  the  bronchial  glands.  Or 
it  mav  have  arisen  from  a  new  infection,  the  infectious  material 
for  which  mav  have  originateci  with  the  patient  himself  l)y  the 
dissemination  of  his  secretions. 

Open  glands  or  bone  lesions  ma\-,  bv  infection  through  the 
wound,  lead  to  serious  consequences  and  even  to  death. 

As  the  greater  part  of  the  scrofulous  patients  who  have  died 
of  pulmonary  tuberculosis  are  placed  in  the  lists  of  mortality  under 
that  disease,  we  have  few  dependable  records  even  for  the  genuine 
tuberculous  form,  as  to  ho^v  often  scrofulosis  runs  a  fatal  course, 


COURSI':    AND    IHiKAIKJN    Ol'     I  III-,    hlSlvASE  225 

C— MIXED   INFECTION. 

The  pictures  wliicli  vv('  have  li(-re  re|)i(;senU;d  of  llie  luber- 
culous  cind  the  pyogenous  form  of  scrofulosis  are  not  always  so 
clear,  but  often  appear  coincidenlally  or  arc  mixed,  both  sorts  of 
bacteria  attacking  the  saiiK;  region,  somriinics  the  lubcrcjf-  barilhis 
first,  sometimes  the  pus  cocci. 

They  may  act  conjointly  and  each  assist  the  work  of  the 
other.  Thus,  pus  cocci  may  cause  acute  or  subacute  inflammation 
in  a  caseous  gland  which  has  existed  for  months,  just  at  the  time 
when  the  chronic  tuberculous  lesion  was  on  the  point  of  encysting. 
The  lesion  is  invaded,  irritated,  the  bacilli  mobilized  and  their 
dissemination  assisted,  with  all  its  dangerous  consequences. 

Very  frequently  the  course  of  tuberculous  glands  is  influenced 
by  accidental  bacteria  and  suppuration  caused  by  them.  v.  Brun's 
researclies  have  demonstrated  that  in  thirt}'-nine  cases  of  sup- 
purated tuberculous  neck  lymphomata,  in  twenty-eight  of  the 
cases  streptococci  co-operated  simultaneously  (this  was  demon- 
strated partly  microscopically,  partly  by  plate-cultures).  Achard 
and  Ramond  observed  secondary  sporotrichosis  in  the  fistuke  of 
tuberculous  glands. 

But  mixed  infection  does  not  always  result  in  harm  to  the 
patient.  The  inimical  species  compete  against  each  other, 
mutually  exhaust  the  nourishment  in  their  narrow  zone,  injure 
each  other  bv  the  products  of  their  changes  and  decomposition, 
and  often  incite  the  tissues  to  increased  inflammatory  reaction. 
As  for  the  latter  case,  highly  virulent  pus-cocci  may,  if  they 
should  enter  a  gland  already  undermined  by  tubercle  bacilli,  act 
like  a  spark  in  a  powder  barrel.  They  cause  acute  suppuration 
which  expels  both  intruders,  the  tubercle  bacillus  and  the  pus 
coccus,  with  partial  or  complete  destruction  of  the  gland  it  is  true, 
but  to  the  benefit  of  the  whole  organism  ;  thus  it  happens  now  and 
then  that  the  whole  of  the  symptoms  of  scrofulosis  disappear  after 
acute  inflammation  of  the  glands  with  abscess  formation  and 
removal  of  pus  and  caseous  matter. 

It  will  be  readilv  understood,  after  all  these  statements,  that 
it  is  hardly  possible  to  fix  a  certain  time  for  the  duration  of 
scrofulosis.  It  drags  on  for  months  and  years,  and  in  the  tuber- 
culous form  even  long  after  the  arrival  of  puberty ;  but  the  non- 
tuberculous  (the  pyogenic)  form,  on  the  other  hand,  disappears, 
for  the  above-mentioned  reasons,  on  arriving  at  the  age  of 
puberty. 


15 


•SECTION  V, 

Prognosis. 


'liiE  prognosis  of  scroiulosis  is  cU'jieiulcni  on  its  torni,  ils 
duration,  and  the  social  position  of  the  patient,  as  well  as  certain 
external  conditions.  On  the  whole,  children  at  the  breast  are, 
with  respect  to  scrofulosis,  more  favourably  situated  prognostically 
than  those  only  partly  suckled,  and  much  more  so  than  those 
artificially  nourished. 

Pyogenic  scrofulosis,  in  which  there  are  no  tubercle  bacilli, 
admits  of  a  favourable  prognosis;  quoad  viUiin,  it  may  be  termed 
mild.  Certainly  at  times  it  is  followed  by  phenomena  which 
disturb  the  functions  of  the  body  or  in  other  ways  indirectly 
endanger  life.  For  example,  disfiguring  ectropia  are  formed, 
corneal  ulcers  with  considerable  restriction  of  vision,  even  blind- 
ness, restriction  of  hearing,  or  breathing  through  the  mouth  owing 
to  adenoid  growths  ma\'  cause  se\ere  infection  of  the  respiratorv 
passages. 

But  if  such  unfortunate  consequences  are  not  induced  the 
scrofulous  symptoms  disappear  spontaneously  towards  or  after 
commencement  of  puberty,  when,  as  it  seems,  the  permeability 
of  the  tissues,  and  therefore  the  power  of  propagation  of  the 
bacteria  is  reduced,  the  body  regains  its  strength,  and  the  person 
mav  for  the  ftiture  enjoy  excellent  health. 

In  the  tuberculous  form  of  scrofulosis  the  patient  feels  himself 
in  a  manner  on  the  down  path  of  his  existence.  One  cannot  tell 
whether  or  when  the  standstill  wdll  come. 

Tuberculous  skin  affections,  lupus,  &c.,  although  they  mav 
be  extensive  and  cause  disfiguring  disturbances,  do  not  present, 
as  a  rule,  quoad  vitam,  any  great  danger  when  there  are  no  com- 
plications. The  glands,  when  only  one  group  is  attacked,  give 
hopes  that  the  process  may  be  localized.  The  more  glands 
attacked,  or  when  several  groups  are  affected,  the  less  is  the 
prospect  of  recovery,  and  the  more  are  dangerous  complications 
threatened. 


PROGNOSIS  227 

In  tlie  lliird  stage,  when  lIk;  bcjiif-s  are  reached)  ili'-  jjiognosis 
must  be  grave.  Even  should  improveinent  lake  place  the  jjalient 
still  stands  on  a  v(^lcan(j,  is  not  sure  for  (Mie  moment  that  a  further 
dispersal  of  llie  bacilli  will  iiol  lake  jjlace  which  may  jjt-rhaps 
destroy  life. 

Even  if  such  a  sad  eveni  should  not  occur,  the  h^ng-continued 
suppuration  may  undermine  I  he  \iialii)-,  and  lead  t(j  the  end  by 
amyloid  degenerati(jn. 

On  the  other  hand,  even  extensive  multiple  bone  affections 
can  often  heal  comparati\'ely  and  only  leave  more  or  less  consider- 
able functional  disturbances  to  remind  the  patient  later  of  the 
troublous  times  through  which  he  has  passed.  In  tuberculosis  of 
the  joints  we  may  reckon  that  75  per  cent,  will  heal. 

The  prognosis  depends,  loo,  on  age. 

With  infants  even  tuberculosis  of  the  bronchial  glands  runs 
a  swift  course,  the  child  becomes  thin,  dyspnoea  appears,  and  often 
suffocating  symptoms  and  death  ensue. 

The  older  the  patient  becomes  the  more  will  the  tuberculous 
scrofulosis  be  localized,  and  the  further  spread  of  the  bacilli  in  the 
body  hindered. 

A  favourable  social  position  which  allows  of  the  arrangement 
of  good  hygienic  conditions  and  the  removal  of  the  child  from 
infectious  surroundings  decreases  the  danger  of  fresh  infection 
and  improves  the  prospect  of  cure,  therefore  the  state  of  health 
of  the  family  has  considerable  influence,  for  the  more  the  child  is 
in  the  companionship  of  tuberculous  persons  the  greater  the 
danger  of  constantly  repeated  infection. 

In  any  case  the  tuberculous  form  of  scrofulosis,  tuberculosis 
of  the  glands,  skin,  and  bones  takes  a  milder  course  with  better 
prospects  of  return  to  health  than  tuberculosis  of  the  internal 
organs ;  for  this,  the  so-called  genuine  typical  tuberculosis,  is 
rightly  considered  to  be  absolutely  fatal  in  infancy,  and  during 
the  whole  of  childhood  as  extremely  unfavourable  and  much  more 
dangerous  than  in  adults  (see  Czerny). 

Recently  we  have  been  much  inclined  to  take  a  less  serious 
view  of  tuberculosis  in  children ;  the  under-current  of  error  in  this 
may  be  summed  up  in  the  sentence  :  "  Our  opinions  of  the 
prognosis  of  children's  tuberculosis  have  improved  since  v. 
Pirquet's  method  was  introduced";  that  means,  in  other  words, 
nothing  more  or  less  than  that  now  we  not  only  include  all  cases 
of  (internal)  tuberculosis  which  are  clinically  certain,  but  also  all 
the  doubtful  phenomena  if  they  have  onlv  been  guaranteed  bv 
V.  Pirquet's  reaction ;  amongst  these  there  will  clearlv  be  manv 
which  react  positively  on  account  of  a  non-dangerous  focus  alreadv 


228  SCROFLLOSIS 

healed,  a  bo\  ine  focus,  which  then  gives  the  harmless  pleasure  of 
reacting  prompily  lo  every  treaiment,  so  leading  us  lo  suppose 
that  we  may  make  the  note  "  Standstill  and  improvement,"  and  it 
is  from  such  cases  as  this  that  Czern)-  says,  "  the  cases  in 
institutions  are  recruited,  for  it  is  frequently  no  tuberculosis  ai  all." 
If  we  lake  all  the  blank  cartridges  of  tuberculous  bovine 
infection  as  hitting"  the  mark,  naturally  the  proportion  that  strike 
the  target  in  the  ball  cartridges  of  human  infection  is  much 
reduced. 

As  opposed  to  the  great  mortality  in  the  tuberculosis  of  child- 
hood, we  frequently  meet  with  persons  who  clearly  have  stiiTered 
formerly  from  scrofulo-tuberculosis — it  may  be  that  their  dis- 
figuring scars  betray  it,  or  that  at  the  time  its  nature  was  clearly 
demonstrated  by  the  bacilli — persons  who  reach  a  great  age  in  the 
enjoyment  of  perfect  health. 

Endeavours  have  been  made  to  explain  in  various  ways  this 
mild  course  of  scrofulo-tuberculosis. 

Those  authors  who  attribute  to  scrofulosis  not  onK'  |)ariial 
diathesis  within  anatomical  Hmils,  but  a  general  diathesis  com- 
prehending the  whole  body,  will  have  most  difficulty  in  finding  a 
reason  for  this,  for  how  will  they  be  able  to  explain  that  the  mild 
course,  due  from  their  point  of  view  to  scrofulous  diathesis, 
suddenly  turns  to  the  opposite  when  the  bacilli  establish  themselves 
outside  the  glands,  for  example,  in  the  lungs?  How  will  they 
be  able  to  explain  that,  for  instance,  in  children  suffering  from 
pulmonary  tuberculosis,  scrofulous  phenomena  suddenly  make 
their  appearance  with  benign  glandular  course,  whilst  the 
pulmonary  tuberculosis  is  hastening  the  end?  Where  is  tlie 
protective,  general  scrofulous  disposition  which  leads  to  a  benign 
course  ? 

^loro  and  others  consider  the  reason  of  the  mildness  to  be  in 
the  irritability  of  lymphatic  tissue  which  is  disposed  to  scrofulosis, 
in  the  violent  reaction,  which  they  look  upon  as  an  act  of  self- 
defence  by  which  the  bacilli  are  hindered  in  their  action.  A 
healthily  reactive  tissue  is  without  doubt  a  means  of  defence,  but 
who  w'ill  make  us  believe  that  this  unhealthv,  excessive,  plentiful 
lymphatic  exudative  reaction  can  be  compared  with  the  healthy, 
strong,  normal  reaction,  and  that  its  effects  are  of  equal  value?  I 
have  made  the  comparison  in  another  place  that  the  effect  of 
scrofulous  reaction  can  just  as  little  be  placed  on  the  same  plane 
as  healthy  reaction,  as  the  spongy,  limp  granulation  in  a  healing 
wound  can  be  compared  wMth  healthy,  strong  granulation. 

Added  to  all  this  comes  Czerny's  assurance  that  he  has  put 
an  end  to  exudative  diathesis  in  the  scrofulous  (that  is  to  say, 


I'KOGNOSIS  22fJ 

wlial  Moro's  "  .'icl  of  scll-dclcncc  "  criccls)  hs'  liis  (lidinj^f  indluKls, 
and  (ln'oLigli  llicni  lias  changed  lli<-  foriiu'i"  s*  lolulfjus  <:liildrfn 
"  into  line  children  wilh  luljerculosis."  \i\cn  il  we  d(;  nol  need 
to  lake  this  literally,  it  appears  at  least  (hat  the  improvement  in 
the  exudative  part  of  the  scrofulosis  did  not  I'-ad  to  an  aggravation 
of  the  tuberculosis,  and  did  not  chang('  il  inio  flic  "  dreaded  " 
genuine  tuberculosis,  yc\  ihis  must  have  happened  if  Moro's 
theory  was  correct,  'rims  ilic  liicoiy  of  Moro  does  nf)l  advance 
our  knowledge. 

The  difference  in  the  course  antl  prognosis  may  be  rather 
explained  by  the  difference  of  localization  by  contrasting  the 
harmless  scrofulosis  of  the  glands  with  the  harmful  tuberculosis 
of  the  internal  organs  in  childhood  ;  at  least  here  we  have  a  basis 
of  facts. 

It  is  all  the  same  if  we  seek  the  cause  in  the  anatomical 
peculiarities  of  the  surrounding  encysted  glands,  with  their  small 
inlets  and  outlets  in  opposition  to  a  focus  surrounded  in  its  whole 
periphery  by  lymph  paths  and  lymph  spaces,  for  example,  in  the 
lungs  or  spleen,  by  which  a  dispersal  of  the  processes  is  favoured 
from  the  first,  or  if  we  lay  the  principal  stress  on  the  retarding 
influence  of  the  retained  toxins  and  lymphocytes  (mentioned  on 
p.  128),  or  with  Bartel  impute  to  the  gland  tissue  a  special  quality 
of  checking  development  and  perhaps  of  immunizing,  the  fact 
that  the  lymph  glands  advance  the  tuberculous  process  less  than 
other  organs  is  hardly  to  be  contested. 

In  a  lesser  degree  and  with  a  somewhat  modified  explanation 
this  agrees  too  for  skin  and  bone.  Much  is  explained  by  this. 
But  is  this  the  only  reason  why  scrofulo-tuberculosis  takes  a 
milder  course  ? 

Why  does  the  tuberculous  infection  remain  localized  in  the 
glands  nearest  to  the  point  of  entry  in  only  a  part  of  the  cases,  in 
the  neck,  mesenteric  and  bronchial  glands,  and  frequently  "  heal 
spontaneously  even  under  unfavourable  circumstances  "  (Czerny) 
while  in  other  cases  it  advances  ? 

Perhaps  animal  medicine  and  experiment  will  give  us  infor- 
mation. Let  us  go  into  the  cowsheds  of  the  Imperial  Health 
Bureau. 

Why  in  one  of  the  calves  does  the  tuberculous  infection 
remain  localized  in  the  nearest  neck  gland,  the  prescapular  gland? 
Why  does  it  induce  here  a  tumour  as  large  as  a  hen's  or  goose's 
egg,  as  in  scrofulosis  w-hich  retrogrades  spontaneouslv,  with  or 
wnthout  opening  after  some  months  ?  Whv  do  these  calves  remain 
healthy  later,  Avhilst  other  calves  get  the  same  glandular  processes, 
which  become  worse  and  lead  to  the  death  of  the  animal  ?     Is  it 


230  SCROrULOSIS 

perhaps  because  the  calves  are  differenlly  disposed  and  one  has 
exudative  tendencies?  No.  Because  they  are  differently  infected, 
the  latter  with  the  bovine  bacillus,  that  of  his  own  species;  th? 
others  with  a  foreign  species,  the  human  bacillus. 

Now  we  know  inversely  that  the  bovine  bacillus  in  man 
behaves  itself  similarly  to  the  human  bacillus  in  cattle.  We  iind 
that,  in  spite  of  the  numerous  opportunities  for  infection  with 
milk,  butter,  and  cheese  from  tuberculous  animals,  that  the  bovine 
bacilltis  is  hardl\'  ever  present  in  adults;  in  children  in  cases 
running  a  severe  course  it  is  rarely  the  cause.  On  the  other  hand, 
in  neck  glands  which  necessitate  operation  we  find  them  in  about 
one-third  of  the  cases,  and  in  minor  glandular  changes  which  have 
hitherto  been  but  lilllr  t^xamincd  \\t'  mi^lit  in  all  prohahililN  fiiul 
them  much  oftener. 

Koch  terms  the  cases  in  which  the  bovine  bacillus  is  said  to 
have  caused  general  and  fatal  tuberculosis  in  man  as  not  "  free 
from  doubt."  Certain  doubts  seem  indeed  to  be  justified,  but 
even  if  we  do  not  share  Koch's  point  of  view,  nor  completely 
acknowledge  the  fatally  ending  cases  in  which  bovine  bacilli  were 
(also?)  found,  it  is  clearly  a  very  small  number  of  strains  which 
lead  to  such  an  issue  in  man  or  in  children. 

But  what  is  remarkable  is  the  fact  that  in  tuberculosis  of  bones 
and  joints,  which  is  also  frequently  noticeable  for  the  benign 
course  it  takes,  hitherto  bovine  bacilli  have  rarely  been  found,  for 
if  these  affections  had  arisen  from  scrofulous  neck  and  mesenteric 
glands,  the  bovine  bacilli  might  be  expected  to  be  met  with  more 
often.  Certainly  Krompecher  and  Zimmermann  formerly  stated 
that  the  chronic  course  of  tuberculosis  of  the  bones  did  not  depend 
upon  the  virulence  of  the  bacilli. 

It  would  lead  us  too  far  to  discuss  here  the  extent  to  which 
special  conditions,  such  as  infection  from  the  perhaps  rarer  bovine 
tuberculous  bronchial  glands  or  change  in  the  hitherto  little 
examined  material  from  tuberculosis  of  the  bones  (greater  age, 
&c.,  &c,),  and  other  factors  play  a  part. 

For  a  number  of  cases,  about  one-third,  it  is  our  fixed  opinion, 
though  the  researches  have  really  only  just  begun,  that  a  consider- 
able part  of  scrofulosis  is  induced  by  the  bovine  bacillus,  and 
that,  being  a  bacillus  of  a  foreign  species,  is  the  cause  of  the  milder 
course. 

For  the  future,  in  any  special  case  to  make  the  prognosis  as 
sure  as  possible  on  all  sides,  we  ought  not  to  fail  to  find  out  with 
which  bacillus  we  are  dealing. 

For  the  further  question,  which  is  very  important  for  the 
prognosis,     is,    how    far    the    primarv    tuberculous    infection    in 


l'R(X,NO.SIS  231 

scrolulusis,  wheLlicr  iL  be  Iniman  or  bt^vinc  species,  can  iiilluence 
the  later  fate  of  the  patienl  il  a  li(-sh  inbcrculous  infection  should 
take  place,  souk;  authors  have  riKlcavoiircn  lo  \)y\n^  lo  bglit  some 
theories  which  appear  Uj  me  lo  be  vry  lar  leLched,  without  for 
the  present  being  able  to  support  (Ihih  by  proved  facts. 

We  will  give  a  few  theories  without  slating  any  opinion  about 
them.  \-.  Uehring  has  stated  ihal  a  Inberciilous  inteciion  which 
has  been  conlracled  in  childhood  and  later  arrested,  cxijiains,  on 
the  one  hand,  the  pr(jporlionalely  great  immuniiy  of  most  adults 
to  tuberculosis;  on  the  other  hand,  it  explains  also  the  decidedly 
chronic  course  which,  as  a  rule,  tuberculosis  takes  in  adults.  The 
expected  proofs  of  this  theory  have  not  been  brought  forward. 

Other  authors  lean  to  the  point  of  view  that  the  hrst  infection 
chiefly  renders  the  patient  more  or  less  immune,  but  with  general 
individual  tendency  a  scrofulous  diathesis  arises,  so  that  the  first 
infection  is  no  longer  able  to  protect  from  the  second  (Edens). 

Hamburger  terms  tuberculosis  a  child's  disease  which  nearly 
every  one  takes,  and  which  lends  a  certain  immunity  to  infection. 

HiJtinel  and  LerebouUet  suppose  an  early  infection  of  the 
mediastinal  and  mesenteric  glands.  The  first  infection  remains 
latent,  and  may^  either  almost  immunize  or,  on  the  contrary,  render 
the  patient  more  susceptible;  the  disease  becomes  manifest  in 
connection  with  other  illness  or  renewed  tuberculous  infection. 
Older  children,  because  they  are  not  affected  so  frequently  as 
infants,  are  said  to  enjoy  a  certain  immunity. 

Weber  is  inclined  to  believe  that  a  body  already  infected  by 
human  bacilli  is  more  capable  of  withstanding  bovine  infection 
instead  of  being  more  susceptible.  He  bases  his  theory  on  the 
case  of  two  children  who  were  infected  by  the  human  bacillus, 
and  who,  in  spite  of  drinking  milk  from  a  cow  with  tuberculosis 
of  the  udder,  on  post-niortciu  examination  exhibited  no  lesions  of 
bovine  bacilli.  But  manv  other  children,  not  the  subjects  of 
human  tuberculosis,  who  drink  bovine  tuberculous  milk  also  do 
not  exhibit  bovine  bacilli ;  thus  there  is  no  visible  foundation  for 
the  belief  of  greater  power  of  resistance  in  Weber's  children. 

Burckhardt,  on  the  other  hand,  relies  on  experiments  on 
rabbits  to  confirm  whether  the  incorporation  of  human  bacilli  at 
an  earlv  age,  when  thev  have  not  yet  induced  immunitv  from 
bovine  tuberculosis,  does  not  favour  spontaneous  infection  with 
bovine  bacilli,  or  does  not  cause  an  already  existing  infection  to 
burst  forth. 

The  facts  that  scrofulous  persons  frequently  by  taking  a 
second  infection  are  subject  to  pulmonary  tuberculosis,  when  both 
diseases  appear  to  merge   into   each   other,    that   the   scrofulous 


23-2  SCROFULOSIS 

frequenih'  recover,  and  yet  sooner  or  later  suffer  from  pulmonary 
tuberculosis,  and  again,  others  often  remain  lieallhy  liirouglioui 
their  whole  life,  that  both  types  of  bacteria,  bovine  and  human, 
are  very  often  found  living  apparently  peacefully  side  by  side, 
and  yet  working  at  the  destruction  of  ihe  body,  cause  us  to  pause 
with  all  these  hypotheses  before  us,  for  up  till  now  no  support 
which  can  be  accepted,  to  say  nothing  of  no  exact  proofs,  have 
been  adduced;  after  all,  they  are  chiefly  mere  variations  of  v. 
Behring's  views.  It  is  true  the  questions  of  the  researches  into 
immunity  are  combined  with  great  difficulties,  for  the  behaviour 
of  the  animal  which  has  been  infected  with  a  quantit}-  of  weakened 
or  otherwise  changed  bacilli  in  the  attempt  to  immunize  it  affords 
us  no  certain  conclusion  about  the  conditions  which  man  would 
show  under  natural  circumstances  after  infection  with  a  few  bacilli. 
We  have  seen,  for  example,  how  far  we  have  succeeded  with 
the  stamping  out  of  tuberculosis  in  cattle  w-hich  years  ago 
promising  experiments  led  us  to  believe  would  be  achieved,  and 
how  short  a  time  the  immunizing  power  remains.  In  this  question 
we  have  erred  too  far  from  the  path  of  exact  research  and  have 
fallen  into  the  channels  of  speculation. 


SrXTION   VI. 

Diagnosis. 


The  decision  \vh('llH'r,  in  corlain  casfs,  we  liave  really  to  do 
with  scrofulosis  is  not  cilways  easy,  in  spite  of  often  striking 
symptoms  in  the  beginning.  Many  processes  manifest  them- 
selves as  tuberculous  from  the  first;  most  of  the  symptoms,  how- 
ever, especially  those  of  pyogenous  scrofulosis,  may  appear  alone 
without  scrofulosis. 

A.— THE  PYOGENOUS  FORM. 

Owing  to  our  hitherto  imperfect  statistics  (see  p.  153),  we 
cannot  judge  how  far  being  descended  Irom  parents  who  at  the 
time  of  generation  were  scrofulous  or  oliierwise  weakened, 
influences  the  transmission  of  a  local  or  general  diathesis,  and 
how  far  this  influence  may  be  diagnostically  utilized  in  the  history 
of  the  case. 

Further  processes,  such  as  mapped  tongue,  milk-scurvy, 
seborrhoea  strofulus  may  raise  the  suspicion  of  scrofulosis.  but  we 
must  be  careful  not  to  be  too  generous  in  our  conception  of  scrofu- 
losis, and  put  down  to  it  every  rash  and  every  swollen  gland  in 
children. 

Nearlv  all  the  symptoms  which  pyogenous  scrofulosis 
presents — eczema,  impetigo,  chronic  rhinitis,  oz£ena,  adenoid 
growths,  otorrhoea,  chronic  swelling  of  the  l\-mph  glands — are  not 
of  themselves  characteristic,  and  appear  singly  in  non-scrofulous 
persons  who  are  otherwise  healthy.  But  yet  they  exhibit  peculiari- 
ties in  their  course  in  scrofulous  persons  which  are  missed  in  the 
healthv,  though  these  peculiarities  are  only  slow  in  their  process, 
as  is  always  the  case  in  the  scrofulous  disposition,  but  which 
appear  to  be,  as  we  have  already  explained,  only  a  higher  degree 
of  anatomical  characteristics  peculiar  to  childhood. 

The  differences  in  the  course  are  the  following  :  those  pro- 
cesses   have    more    opportunitv    of    establishing    themselves    on 


234  SCROFULOSIS 

account  of  the  more  open  and  wider  points  of  entry,  therefore  are 
extraordinarily  apt  to  relapse  (recurrence),  and  similar  processes 
appear  simultaneously  or  following  each  other  (multiplicity), 
further,  owing  to  the  wider  lymph  passages  they  can  more  easily 
spread,  and  are  more  difficult  to  remove  (pertinacity),  and  can 
especially  invade  the  lymph  glands. 

It  is  onlv  these  special  signs  which  justify  the  conclusion 
that  a  focus  is  due  to  scrofulosis,  and  especially  the  multiplicity 
of  places  not  directly  dependent  on  each  other  or  at  short  intervals 
is  of  great  importance.  On  the  other  hand,  otorrhoea  may  depend 
on  eczema  of  the  auricle,  nasal  catarrh  on  adenoid  growths,  with- 
out on  this  account  imputing  them  to  scrofulosis. 

In  this  CDnncclion  the  remains  of  former  similar  processes 
mav  be  valuable  in  diagnosis,  for  example,  ulcers  on  the  cornea, 
perforation  and  scars  on  the  membrana  tympani,  high,  narrow, 
boat-shaped  palate  with  irregular  teeth,  scars  about  the  glands  in 
the  neck,  as  well  as  certain  consequent  symptoms,  which  are  often 
described  in  the  picture  of  the  scrofulous  habitus,  the  thick  puffy 
nose,  the  swollen  upper  lip,  with  a  perpendicular  crack  in  the 
middle. 

Eczema  appears  in  quite  healthy  persons,  is  induced  by 
pediculi,  for  instance,  or  other  causes,  but  in  the  scrofulous  it  is 
especiallv  frequent  and  obstinate.  But  this  must  not  be  mistaken 
for  eczema  seborrhoicum,  which  is  caused  merely  by  an  accumu- 
lation of  sebaceous  matter.  We  must  also  keep  impetigo 
contagiosa  (pseudo  scrofulosis  of  Chaumier)  with  its  decidedlv 
contagious  character  distinct. 

Many  forms  of  lichen  scrofulosorum  belong  to  pyogenous 
scrofulosis,  if  they  have  not  a  tuberculous  basis  and  growths  like 
tuberculides. 

The  same  may  be  said  of  chronic  rhinitis  which  may  have 
been  induced  by  foreign  bodies  artificially  introduced  or  other 
causes;  this  may  be  of  long  duration  even  in  healthy  persons,  but 
is  seldom  permanent  as  in  scrofulosis. 

Pins  lays  special  weight  on  the  continued  and  regular  swell- 
ing of  the  nose,  and  a  certain  sensitiveness  to  pressure  as  a  sign 
of  scrofulous  rhinitis. 

Oza^na,  whether  it  is  consequent  on  chronic  rhinitis,  or  is 
directly  induced  by  certain  bacteria,  is  more  frequent  in  scrofu- 
losis, and  in  children  justifies  suspicion  of  scrofulosis,  otorrhoea 
also  when  it  is  of  inordinately  long  duration,  and  is  combined 
with  eczema  of  the  auricle  and  swelling  of  the  cervical  glands. 

Swelling  of  the  tonsils,  and  especially  adenoid  growths,  may 
in  their  later  symptoms  easily  assume  the  semblance  of  tubercu- 


DIAGNOSIS  235 

losis,  buL  llic'ir  speedy  discippi-arancc  and  die  lack  ol  all  di(;se 
symptoms  after  rational  treatment  and  operative  removal  is 
against  scrofulosis. 

I  have  referred  alxn'e  (see  |).  KjH)  \()  (lie  j^r'-'-nisli-hiown 
colourinj^-  of  i\\('  leedi  noted  by  Neumann. 

The  marked  dislike  to  light  in  pit! ycleniilar  and  odier  affec- 
tions of  the  eyes  has  also  been  said  l<>  be  a  sign  of  scrofulosis. 

Skin  affections  in  the  tributary  area  of  the  glands  are 
especially  valuable  as  an  indication  of  die  nature  of  the  glandular 
swelling.     (vSe(;  Topography,  p.  i.V'O 

One  or  two  swollen  glands  in  the  neck  or  elsewhere  is  no 
sign  of  scrofulosis.  Acute  glandular  swellings  are  naturally 
exempt  from  such  significance  as  being  caused  by  some  infectious 
irritation  near  the  seat  of  the  swelling;  they  disappear  in  a  few 
days  (^r  pass  off  with  inflammation,  fever,  rapid  breaking  down, 
and  suppuration.  There  are  also  a  great  number  of  chronic 
swellings  which  have  nothing  to  do  with  scrofulosis,  they  are  more 
painful,  disappear  more  easily,  especially  when  the  exciting  cause 
in  the  source  of  the  disease  is  healed. 

B.— THE  TUBERCULOUS  FORM. 

(1)  Clinical  Diagnosis. 

The  history  may  give  important  data  for  the  diagnosis  of 
the  tuberculous  form.  The  so-called  heredity,  that  is  to  say,  the 
existence  of  the  disease  in  the  family,  is  most  significant  in 
tuberculo-scrofulosis,  certainly  not  in  the  sense  used  in  former 
times  and  often  also  in  the  present  day  as  indicating  that  the  child 
was  predestined  to  it,  but  on  account  of  the  opportunities  of 
contagion  arising  out  of  it. 

The  state  of  health  of  the  parents  at  the  time  of  the  pro- 
creation and  birth  of  the  child  would  give  us  important  informa- 
tion for  the  diagnosis,  if  only  we  could  accustom  ourselves  not  to 
dismiss  everything  with  the  watchword  heredity  (see  Hereditary 
Influences,  p.  154). 

We  ha^■e  not  onlv  to  notice  from  the  one  point  of  view  the 
state  of  health  of  the  parents,  but  also  that  of  the  persons  with 
whom  the  child  comes  most  into  contact  (relations,  servants,  plav- 
mates),  and  must  in  this  connection  direct  our  attention  to  the 
mode  and  intensity  of  the  spread  of  the  infectious  material. 
Besides  which,  we  must  confirm  how  far  social  conditions,  certain 
diseases,  measles,  (Src,  or  other  favouring  factors  make  the 
diagnosis  probable. 

Tuberculous  scrofulosis  exhibits  principally  a  multiplicity  of 


236  SCROFULOSIS 

phenomena  in  ilic  iniernal  organs  of  ilu-  hotly  and  a  gieai  perti- 
nacity, the  pyogenoLis  form  a  muliipliciiy  on  the  surtace  of  the 
body  and  frequent  recurrence. 

The  diagnosis  of  the  tuberculous  form  can  be  lurihcr  sup- 
ported by  the  demonstration  of  specific  skin  chseases — kipus, 
scrofuloderma,  lichen  scrofulosorum — the  external  phenomena  of 
which  we  described  above,  whilst  for  the  differential  diagnostic 
signs  we  must  refer  lo  ihc  special  scciion  of  ihc  work  on  Skin 
Diseases. 

We  must  especially  refer  to  luptis  of  die  mucous  nicmlirane 
of  the  nose  in  the  vestibule  of  the  nose  in  the  anterior  angle  as 
one  oi  the  most  frequent  starting-points  of  lupus  of  the  face, 
which,  on  account  of  its  hidden  position  and  its  benign  course, 
is  frequent  1\'  (ncrlooked  or  i:)ut  down  to  eczema  (Gerber  and 
Senator). 

The  demonsiralion  of  tuberculides,  of  lichen  scrofulosorum, 
of  erythema  nodosum,  of  ft)lliculilis  has  doubtless  hii^h  diagnostic 
significance  for  scrofulous  tuberculosis,  as  was  most  emphatically 
noted  by  Boeck  many  years  ago. 

In  tuberculosis  of  infants  there  were,  according  to  L.  F. 
Mever,  tuberculides  in  50  per  cent. ;  Leopold  and  Roseniern  found 
the  tuberculides  described  by  Hamburger  twelve  times  in  thirty 
cases.  But  we  are  not  justified  in  considering  these  lesions  off- 
hand as  a  sign  of  general  tuberculous  infection,  for  they  may  arise 
as  the  result  of  a  toxin,  and  especially  by  dead  bacilli  of  both 
types,  human  and  bovine. 

Now  and  again  tuberculides  may  be  mistaken  for  syphilitic 
exanthemata,  and  the  diagnosis  can  only  be  confirmed  by  Wasser- 
mann's  reaction;  the  refractory  character  of  antisvphilitic  treat- 
ment and  the  local  tuberculin  reaction  establish  the  diagnosis 
(Konigstein), 

A  case  of  Sergent  shows  what  dif^culties  now  and  then 
present  themselves  in  diagnosis.  A  woman  who  was  declared  to 
be  tuberculous  seven  years  after  her  marriage,  and  who  had  a 
series  of  skin,  gland,  bone  and  joint  affections,  turned  out  to  be 
syphilitic,  and  was  cured  by  antisvphilitic  treatment. 

The  rest  of  the  symptoms  in  the  skin,  eczema,  impetigo — and 
in  the  mucous  membranes,  catarrh,  ozrena,  rhinitis,  phlvctenc'e — 
owe  their  origin  perhaps  to  the  same  scrofulous  tendencv,  but  are 
not  connected  directly  with  tuberculous  affections.  If  bacilli  are 
present,  as  in  some  cases  of  eczema,  ozasna,  and  adenoid  growths 
has  been  demonstrated  (see  pp.  ti,  12  and  141),  thev  denote  a 
second  infection;  the  proof  of  this  is  important  in  so  far  as  they 
also  confirm  tlie  character  of  the  accompanving  glandular  swelling. 


DIAGNOSIS  2.37 

Otorrlicjca,  too,  need  iiol  (Icpciid  mi  i  iilxTcuUjsis,  alilioiigli  il 
often  owes  its  origin  lo  n.  I  Ins  is  shown  by  the  pn^senee  of 
tubcrch;  bacilli  in  llic  scciclinn  nl  ilic  r-;ir,  .-md  pointed  to  by  its 
insidious  [)ainless  (^cciirrence,  and  es[)e(;ially  by  the  aeefjnipanying 
caries  of  the  petrosal  bon(;.  Also  the  (generally  casealed)  glands 
of  tlie  mastoid  arc;  in  the  pyogenic  lorni  not  so  frequently  met  with. 

Tuberculosis  of  the  Glands. — The  diagnosis  is  considerably 
mor(!  dinicult  when,  as  is  so  rrc(|uently  the  case,  in  (he  tuberculous 
form  there  are  no  spc^cific  synipionis  at  ilie  point  of  entry,  and  we 
iiave  only  tlu;  swelling  of  the  glands  as  guides,  thes<*  having  few 
signs  which  characterize  them  as  specifically  tuberculous. 

The  fewer  the  superficial  affections,  of  course  with  the  excep- 
tion of  specihc  lupus,  the  more  probable  is  it  that  the  swelling  of 
the  glands  is  of  a  tuberculous  nature. 

Thus  we  can  understand  the  notion  of  older  authors.  Hufe- 
land,  for  example,  greeted  the  phenomena  of  scaly  eruptions, 
discharging  ears  and  eyes  as  favourable  signs,  considering  them 
a  diversion  protecting  from  internal  scrofulosis. 

As  long  as  the  gland  is  closed  the  slow,  painless  course, 
which  may  remain  stationary  for  months  or  years  at  the  same 
stage  of  development,  as  well  as  the  presence  of  large  masses  of 
glands  or  the  absence  of  radiating  hypertrophic  scars  as  signs 
of  processes  (tistulce)  which  have  already  healed,  all  point  to 
tuberculosis. 

The  diagnosis  is  relatively  easy  in  the  case  of  the  neck  glands 
which  have  burst,  where  we  can  demonstrate  tubercle  bacilli 
microscopically  in  the  pus,  or  by  inoculation  into  animals  which, 
on  account  of  the  small  number  of  bacilli,  is  more  reliable. 

But  without  this  confirmation  a  thinner  fluid  secretion  mixed 
with  caseous  fragments,  the  unusuallv  long  standing,  and  the 
formation  of  fistulai  are  in  favour  of  tuberculosis,  whilst  thick 
yellow  pus,  acute  course  with  prominent  inflammatory  symptoms, 
and  a  speedy  scarring  rather  indicate  a  different  origin. 

Tuberculosis  of  the  Bronchial  Glands. — Demonstrable  swell- 
ings of  the  bronchial  glands  depend  most  on  tuberculosis,  for  if 
they  swell  from  other  causes — Geffrier,  for  example,  has  noted 
such  cases — experience  has  proyed  that  they  seldom  arrive  at  so 
great  a  size  as  to  induce  characteristic  disturbances. 

General  symptoms  for  which  no  other  reason  can  be  demon- 
strated often  point  to  scrofulosis  of  the  bronchial  and  mediastinal 
glands.  Such  symptoms  are  loss  of  weight,  loss  of  appetite,  often 
dyspeptic  derangements,  easily  becoming  tired,  and  "  feeling 
limp,"  especially  in  the  morning.  We  are  often  seduced  by  a 
pale   face   to  content   ourselyes   with   the   diagnosis    "anaemia," 


238  SCROFLLOSIS 

although  the  stale  of  the  blood  gives  no  ground  for  this  dictum. 
A  correct  record  oi  the  temperature  generally  suffices  to  show  the 
real  state  of  things.  In  this  case  (see  "  Die  rubercuk)se,"  second 
edition,  p.  729)  1  must  especially  emphasize  the  fad  thai  only  by 
a  record  every  twt)  hours  is  it  possible  to  confirm  slight  increases 
of  temperature.  I  have  seen  numerous  cases  of  pulmonary  and 
glandular  tuberculosis  which,  altiiough  accompanied  by  am- 
biguous general  symptoms,  escaped  a  certain  diagnosis  for 
months,  only  because  the  practitioners  had  been  contented  with 
taking  the  temperature  two  or  three  times  daily,  and  were  deceived 
by  its  being  apparenilv  normal,  whilst  on  the  first  day  by  con- 
sistent record  every  iwo  hours  I  confirmed  an  increase  of  tempera- 
ture of  37'2°  lo  37'3°  in  the  arm[)ii,  and  of  over  37'3°  in  the 
rectimi,  with  occasional  transitory  slight  feeling  of  chill,  and  by 
this  means  severe  affection  of  lungs  and  glands  was  demonstrated. 
Man\-  are  still  unilcr  ihe  delusion  that  fever  onl_\-  begins  o\er 
37'7°  (rectum),  and  iluis  miss  the  best  time  for  rational  irealment. 

Avellis  has  found  in  children  from  i  to  8  years  of  age  an 
evening  temperature  of  sS'i'^'  in  the  rectum  for  months  together 
without  tonsillar  enlargement  or  physical  examination  giving  any 
clue.  Suspicion  of  tuberculosis  has  kept  children  for  months  in 
bed  "to  no  purpose."  Avellis  attributes  the  cause  of  local  rise 
of  temperature  in  the  rectum  lo  anaerobic  bacteria,  A\hicli  increase 
the  temperature  locally,  as  the  temperature  of  the  armpit  is  1°  to 
I '2°  lower. 

The  bronchial  and  mediastinal  glands  point  more  clearly  to 
infection.  They  cause  a  convulsive,  reflex,  rough,  dry  cough, 
coming  on  by  fits  and  starts,  lasting  a  short  time,  but  frequently 
recurring,  resembling  whooping  cough,  though  less  seldom 
accompanied  by  vomiting  and  wheezing. 

The  attacks  resembling  pertussis,  which  frequently  occur  after 
swelling  of  the  bronchial  glands,  come  on,  as  J.  Simon  notes,  more 
in  the  morning  and  evening  or  after  exertion,  and  are  less  frequent 
at  night.  The  cough  shows  great  variations  in  intensil}'.  In 
whooping  cough,  on  the  contrary,  the  attacks  are  more  rhythmic, 
the  expiration  forced  and  jerky,  the  inspiration  gasping  or  wheezy. 
This  condition  returns  after  every  five  or  six  attacks  of  coughing, 
and  finishes  with  mucous  expectoration.  The  attacks  are  especially 
frequent  at  night. 

Other  indications  are  hoarseness  (cliiellv  posterior  j^aresis, 
Breeke),  even  complete  aphonia,  now  and  then  a  wheezy  voice, 
followed  by  frequent  catarrh,  Avhich  is  favoured  by  the  reduced 
reflex  activity  of  the  respiratory  mucous  membrane,  in  consequence 
of  compression   of  the  sensitive  branches  of  the  vagus.     Hvper- 


Dl  A(JNO.SJ.S  239 

plasia  of  Lhc  pliaryngcal  vaull,  swcllijig  <>\  ili<-  iif  k  gl;ui(l.s  ;iii'l 
oilier  scrofuh^us  plienom(;na,  jKil{)ila(ion,  (jiik  kciiing  ol  tin;  piil.s<-, 
and  varialion  of  llie  pulse,  now  and  ilnn  enlargement  ol  ilie  pujnl 
on  the  affected  side,  wliicli  for  the  same  reason  ran  also  be  men- 
tioned as  an  early  symptom  of  pulm<jnary  liihcrciihxsis  (Wolfer 
and  others).  Enlargement  of  the  pupil  may  be  artificially  induced, 
according  to  Grover  in  mediastinal  tumours,  if  it  did  not  exist 
before,  by  pressure  after  deep  inspiration,  whilst  in  healthy 
persons  the  pupil  would  diminish. 

Further  signs  are  oedema  of  one  side  of  the  face  (O.  Mijller), 
enlargement  of  the  veins  on  one  side  of  the  neck,  at  the  upper  part 
of  the  chest,  at  the  back  of  the  neck,  often  only  small  stellate  radia- 
tions, rarely  enlargement  of  the  temporal  vein  of  the  same  side 
(Siracoff),  sometimes  bluish  colouring  of  the  face  and  lips,  nose 
bleeding  similar  to  what  is  seen  in  persons  suffering  from  heart 
disease;  later,  increased  frequency  of  breathing,  asthmatic  attacks, 
dysphagia,  and  sometimes  enlargement  of  the  spleen. 

A  child  aged  if  exhibited  purely  expiratory  dyspnoea  under 
the  guise  of  asthma,  accompanied  by  fever.  It  became  thin, 
and  ga've  a  positive  tuberculin  reaction ;  other  signs  such  as 
Rontgen  shadows  were  wanting;  the  post-vioriem  examination 
showed  compression  of  the  trachea  in  the  form  of  a  slit  due  to 
tuberculous  bronchial  glands  (Eckert). 

A  feeling  of  pressure  over  the  sternum,  or  painful  sensitive- 
ness to  pressure  and  tapping  on  the  sternum,  or  between  the 
shoulder-blades  and  on  the  vertebral  column,  especially  on  the 
spinal  processes  of  the  second  to  seventh  dorsal  vertebrae  (Neisser, 
of  Stettin,  and  Petruschky)  are  frequent  characteristics.  This 
spinalgesia  was  found  in  13  per  cent,  of  school  children  in 
Dantzig. 

In  infants  at  first  nasal  snuflling  is  exhibited,  and  later 
expiratory  gurgling,  with  a  hissing  noise  due  to  compression  of 
the  chief  bronchus  with  expiratory  dyspnoea,  especially  when 
crying  or  coughing,  which,  according  to  Schick  and  Sluka  when 
combined  with  positive  reaction  and  the  Rontgen  signs,  is 
sufficient  to  establish  a  certain  diagnosis  (see  Escherich,  \'ariot 
and  Finkelstein). 

Physical  examination  is  of  great  importance.  Over  the  apices 
of  the  lungs,  on  the  right,  in  front  and  behind,  prolonged 
exaggerated  expiration  is  found,  which  posteriorly  and  in  the 
right  suprascapular  fossa  often  shows  a  decided  bronchial  char- 
acter, and  from  the  second  to  fifth  dorsal  vertebrc-e  (at  the  place 
where  there  is  usuallv  vesicular  breathing)  a  loud  blowing  sound, 
often  even  amphoric,   is  audible.     It  is  best  to  let  the  children 


240  SCROFULOSIS 

breathe   with   closed   moiuh   during  ausculialion    in    order   noi    lo 
be  deceived  by  their  gasping. 

II.  Neumann  has  especially  remarked  the  great  value  of  this 
abnormal  breath  sound  at  the  apex  of  the  lung  in  enabling  us  to 
differentiate  it  from  phthisis  of  the  lungs,  in  which  it  is  not 
present,  and  which  is  not  accompanied  by  diminished  resonance 
nor  by  rales,  although  this  abnormal  breathing  at  the  apex  has 
frequently  given  rise  to  an  erroneous  impression  of  pulmonary 
phthisis,  on  account  of  which  children  are  "  taken  into  institutions, 
treated  and  cured." 

Steiner  and  Neureuther,  Widerhofer  and  others  have  also 
emphasized  the  importance  of  this,  and  Widerhofer  especially, 
when  it  is  met  with  on  the  left  side.  I  can  concur  in  this  from  my 
own  experience.  But  Henoch,  Gerhardt  and  Bacinsky  do  not 
attach  much  importance  to  it. 

Below  the  clavicle  and  at  the  back  in  the  central  and  lower 
parts  breathing  and  fremitus  are  weakened  by  pressure  on  the 
chief  bronchus.  When  the  mediastinal  glands  are  affected  we 
hear  a  dulness  in  front,  above  and  near  the  sternum  irregularly  in 
the  first  and  second  intercostal  spaces,  over  the  parasternal  line  on 
one  or  both  sides,  not  extending  very  far,  and  getting  less  marked 
lower  down. 

In  the  back  a  dulness  is  often  perceived  on  the  right  and  left, 
near  the  vertebral  column,  between  the  spine  and  angle  of  the 
scapula  (Escherich  and  Kramer),  and  an  interscapular  weakening 
of  the  breath  sounds,  also  a  loss  of  vocal  fremitus,  or  there  may 
be  abnormal  resonance  in  many  places  (Allan).  The  weakening 
over  the  sternum  and  on  both  sides  of  the  vertebral  column  may 
perhaps  be  caused  by  a  thymus  gland,  or  struma  retrosternalis;  it 
may  lead  to  mistakes,  especially  in  the  first  two  years  of  life,  till 
the  thymus  has  atrophied.  Besides  all  this,  slight  differences  of 
sound  may  be  caused  bv  scoliosis,  even  when  of  moderate  extent. 

Percussion  of  the  vertebral  column  is  very  important,  a  point 
emphasized  by  de  la  Camp.  In  the  group  of  glands  lying  at  the 
bifurcation  of  the  trachea  a  noticeable  relative  deadening  and  an 
increased  feeling  of  resistance  on  the  fifth  and  sixth  spinal  pro- 
cesses of  the  dorsal  vertebrae  is  remarked,  and  can  be  best  heard 
in  a  sitting  posture,  when  the  trunk  leans  slightly  forward  and 
the  shoulders  are  kept  loose  (see  also  Piorry,  Fr.  v.  Koranyi, 
de  la  Camp,  Nagel,  Michalowicz,  "Finkelstein,  Cozzolino,  and 
others). 

As  an  carl\-  sNUipioni  d'Espinc  has  mentioned  bronchophony 
in  ihe  region  of  the  seventh  cervical  and  first  dorsal  vertebrae, 
which,  when  it  lasts  in  an  unchanged  condition  for  several  months, 


DJA(.i\(J.SI.S  241 

leads  us  lo  conclude  die  tuljcrc  nlniis  ii,-iiiiif  <>\  dw  j^'-l,-iiidul--ii' 
swelling. 

The  |)li('ni)incn()n  ()bs<n'ved  by  iCuslacc  Smidi  is  a  very 
valuable  nicins  ol  assistance-,  namely,  a  systolic  murmur,  or  a 
continued  luunndnn^  above  the  manubrium  slerni,  which  is 
perceiv(;d  when  the  head  is  thrown  far  back,  and  is  caused  by  thf; 
pressure  of  the  groups  of  glands  on  the  veins  in  the  chest 
(Neumann,  Shaw,  and  Laird). 

Neisser's  palpation  wiili  die  sound  may  also  render  service 
in  diagnosis.  -He  made  the  bronchial  glands  which  lie  on  the 
oesophagus  accessible  by  introducing  into  patients  who  had  taken 
no  food  for  some  hours  before,  lo  liic  depili  of  about  30  cm.,  a 
thin  soft  sound  which  was  armed  with  an  india-rubber  teat,  and 
which  was  tightly  bound  above  and  below  the  fenestrum ;  by 
injecting  air  with  an  ear  syringe  a  small  bladder  fdled  with  air  is 
raised  at  the  fenestrum  of  the  sound;  by  withdrawing  the  probe 
and  by  repeatedly  inflating  the  whole  region  can  be  palpated.  In 
forty-eight  cases  which  reacted  to  tuberculin,  but  were  without 
other  signs  of  tuberculosis,  Neisser  found  that  forty-two  experi- 
enced pain,  whilst  amongst  250  healthy  persons  there  was 
complete  freedom  from  pain.  But  it  is  a  remarkable  fact  that  after 
one  or  two  years  and  without  any  special  treatment  there  was  no 
further  sign  of  tuberculosis,  so  we  must  admit  the  possibilitv  that 
he  had  to  do  with  cases  of  inactive  foci. 

Sometimes  by  means  of  tracheo-bronchoscopy  the  bulging  of 
an  enlarged  gland  lying  near  the  trachea  or  bronchi  may  be 
recognized,  its  course  may  be  followed,  and  its  point  of  rupture 
afterwards  established  (PoUak  and  Erdely). 

Chiari  by  bronchoscopy  was  led  to  suspect  primary  carcinoma 
of  a  chief  bronchus,  whilst  the  post-mortem  showed  a  tuberculous 
tumour  of  the  lymphatic  glands  which  had  traversed  the  bronchus. 

The  Rontgen  rays  have  proved  of  great  value  in  diagnosis  in 
cases  where,  in  spite  of  severe  tuberculosis  of  the  bronchial  glands, 
clinical  symptoms  were  absent,  for  instance,  in  a  case  of  Variot, 
Heisler  and  Schall,  and  others;  frequently  the  shadow  is  demon- 
strated lying  sliarply  defined  on  both  sides  of  the  hilum.  The 
condition  revealed  by  the  radioscope  is  especially  valuable  as  an 
early  sign  (Barret  relates  1,000  instances);  it  is  verv  dependent  on 
the  condition  of  the  gland;  normal  glands  cannot  be  recognized, 
the  softened  gland  occasionally,  and  the  caseated  or  calcified 
gland,  as  a  rule,  throws  a  very  sharply  defined  shadow,  but  practice 
is  necessary,  together  with  experience  and  cautious  judgment,  to 
avoid  false  conclusions.     The  glands  Iving  near  the  hilum  and  the 

16 


2^2  SCROFLLOSIS 

inira-pulmonarv  glands  can  be  observed  by  posterior  Rontgen 
examination,  thougli  often  still  better  by  anterior  examination, 
and  on  the  right  side  better  tlian  on  the  left;  the  other  glands, 
hidden  bv  the  shadow  of  the  sternum  and  vertebral  column,  can 
best  be  seen  by  lateral  and  oblique  direction  of  the  rays.  Examina- 
tion bv  the  photographic  plate  is  preferable  to  examination  by  the 
screen.  A  negative  result  in  examination  by  the  rays  is,  as  we 
can  understand  by  what  has  already  been  said,  not  a  proof  that 
swelling  or  tuberculosis  of  the  bronchial  glands  does  not  exist  (see 
Barret,  Escherich,  Kohler,  Josserand  and  Roux,  Cozzolino, 
Nagel,  Pierry  and  Jacques,  Allan,  Peer,  Pfaundler  and  Laureati). 

The  lateral  thoracic  lymphatic  glands,  those  which  lie  in  the 
fourth  and  fifth  intercostal  spaces,  between  the  anterior  and 
posterior  axillary  line,  and  which  communicate  with  the  intra- 
thoracic glands,  also  merit  consideration.  At  limes  they  swell 
visibly  and  palpably,  especially  in  infants,  but  also  in  adults 
(Zebrowski)  when  inflammatory  processes  arise  in  the  lungs  and 
bronchial  glands,  and  especially  in  tuberculosis,  sometimes  also 
in  syphilis  (Hochsinger). 

I  will  also  mention  that  Noegerath  and  Salle,  in  a  number  of 
cases  of  bronchial  gland  and  pulmonary  tuberculosis,  ciemon- 
strated  the  presence  of  Head's  zone  of  sensibility,  which  proves 
itself  of  value  in  diagnosis. 

Por  further  particulars  of  tuberculosis  of  the  bronchial  glands 
see  Breeke,  Pinkelstein,  Prench,  Guinon,  Hecker,  Michalowicz, 
O.  Miiller,  Nagel,  Pierry  and  Jacques,  Schick,  Sluka,  Stoll, 
Thiemann,  and  Zumsteeg. 

The  mistaking  for  other  sorts  of  degenerated  glands  or 
mediastinal  tumours  may  be  avoided  by  taking  the  whole  of  the 
symptoms  into  consideration.  The  demonstration  of  simul- 
taneous swollen  mesenteric  glands  (see  p.  208)  affords  the  best 
support  for  the  acceptance  of  a  tuberculous  character.  Por  the 
differential  diagnosis,  see  also  end  of  the  chapter. 

The  mesenteric  glands  frequently  run  their  course  without 
pressure  symptoms  or  functional  disturbances.  Their  presence 
is  indicated,  therefore,  for  a  long  period  only  by  general  symptoms 
and  increase  of  temperature  (temperature  should  be  taken  every 
two  hours,  see  above).  In  other  cases  an  extension  of  the 
abdominal  venous  plexus,  and  long-continued,  and  al  times 
spasmodic,  pains  in  the  abdomen  occur;  sometimes  also  there  are 
cramp-like  pains  in  the  thigh,  the  abdomen  becomes  round  and 
prominent,  and  rises  to  a  point  at  the  navel,  together  with 
obstinate  diarrhoea.  The  mesenteric  glands  become  palpable  only 
when  they  have  attained  a  certain  size.     But  even  then  thev  often 


DJAGNOSIS  243 

escape  ob.servali(jn,  being  covered  by  the  intestines  and  abd(jminal 
wall,  or  when  (lie  abdomen  is  S(;ft  they  may  at  limes  be  df;mon- 
slraled,  or  be  accidciilally  disc(jvered  as  mov.'ible  iiiniours,  dioiigh 
sometimes  fixed  and  at  limes  v(M'y  sensilivf;  l(;  loiu  h,  <^s]Je(;ially  in 
the  region  of  the  navel. 

'1  liey  may  be  easily  diliercnl  inled  from  die  scybala  resulting 
from  obstinate  consli[)£ili(jn  and  wliich  lie  more  in  the  iliac  regifjn 
by  a  laxative  which  causes  them  to  disappear.  A  differentiation 
from  peritonitis,  stenosis,  or  a  kinl<  of  the  intestine  must  bf;  taken 
into  consideration.  Katzenstein  found  in  an  operation  a  group 
of  tuberculous  glands  on  the  vena  cava  which  at  first  had  appeared 
to  be  a  tumour  in  the  slcjmach.  (Xten  a  chronic  swelling  of  the 
spleen  can  be  demonstrated  (see  also  llecker  and  Trumpf,  Ileclit, 
TIantenga  and  Thilmann). 

Should  the  tuberculous  form  of  scrofulosis  have  alreadv 
reached  the  third  stage  fungous,  bone  and  joint  affections  are 
present,  and  there  will  be  less  doubt  as  to  the  nature  of  the  case. 

At  first  these  affections  of  the  bony  skeleton  may  give  rise  to 
many  errors  in  diagnosis.  Pain  in  the  knee,  which  often  long 
precedes  coxitis,  easily  misleads,  especially  when  the  first  stage 
in  the  region  of  the  joint  has  been  overlooked,  and  when  the 
second  stage,  that  of  the  glands,  has  remained  latent.  The  peculiar 
position  when  attempting  to  raise  an  object  from  the  ground, 
lancinating  pains  in  the  legs  and  the  above-mentioned  signs  (see 
p.  210)  point  to  a  spondvlitis. 

In  addition  the  Rontgen  rays  afford  us  extremely  valuable 
information  as  to  the  nature  and  extent  of  bone  affections. 

Garrod  recommends  auscultation  of  the  large  joints  during 
slight  stretching  and  flexion  movements,  in  order  to  help  to  form 
an  early  diagnosis  between  tuberculosis  and  rheumatism  bv  the 
sounds  heard.  An  early  symptom  in  bone  and  joint  tuberculosis 
is  regional  plastic  oedema  of  the  skin  over  or  very  near  to  the 
tuberculous  lesion,  supposed  to  be  due  to  congestion  or  toxic  effects 
<Werndorff). 

It  is  not  the  place  here  to  go  into  the  dift'erential  diagnosis  of 
fungous  and  other  affections  in  bones  and  joints,  and  I  refer  mv 
readers  to  surgical  handbooks. 

One  is  more  easily  deceived  when  apparently  healthy  indivi- 
duals are  attacked,  in  whom,  according  to  former  notions,  tuber- 
culosis W'Ould  never  have  been  suspected  from  their  appearance 
and  family  history.  But  usually  the  general  health  has  suft'ered 
considerably  owing  to  the  long  existence  of  the  affection  of  the 
glands  (whether  it  had  been  latent  or  manifest)  preceding  the 
evidence   of  tuberculosis   without   beinsf  able   to   find   any   other 


244  SCROFULOSIS 

explanalion  of  iliis  loss  of  lu-alth.  Pali'iu-ss,  loss  of  weighi,  or 
insufficient  increase  of  weighi  and  funciional  disiurham-es  point 
to  severe  derangement  of  the  general  organism.  Especially — 
and  we  cannot  emphasize  this  enough — the  greatest  attention 
nuisi  be.  paid  to  the  temperature  (see  p.  238).  W'e  must  never 
neglect,  for  even  one  dav,  to  know  the  exact  state  of  the  tempera- 
ture of  the  body  by  taking  it  every  two  hours  (see  Cornet,  "  Die 
Tuberculose,"  second  edition,  p.  729). 

Clinical   Differential   Diagnosis. 

Scrofulous  lymphomata  dif^'er  from  other  sorts  of  lymjjhomata 
in  the  following  manner  :  they  grow  gradually  to  large  tumours 
and  in  their  later  course  merge  into  each  other  by  periadenitic 
irritation^  and  cannot  then  be  differentiated  by  palpation  from  a 
mass  of  single  glands.  According  to  their  successive  production 
and  their  different  characters-  they  exhibit  in  places  variable 
resistance,  either  becoming  hard,  or  soft  and  fluctuating.  In  the 
places  which  have  softened  and  are  nearly  breaking  the  skin  is 
especially  adherent. 

Leucsemic  Ivmphomata  form  lunioiirs  which  are  sometimes 
the  size  of  the  fist;  they  begin  in  the  neck  and  often  inxolve  the 
whole  of  the  lymph  glands  of  the  body;  as  a  rule  the  skin  is  not 
adherent,  even  when  the  tumours  reach  the  size  of  a  child's  head 
it  will  still  form  a  fold.  Errors  in  diagnosis  may  be  prevented 
by  examination  of  the  blood,  which  exhibits  a  very  great  increase 
of  leucocytes. 

In  the  pseudoleuca^mic  form  we  see  enormously  enlarged 
groups  of  glands  in  large  non-adherent  masses,  which  are  often 
simultaneously  affected,  are  easily  movable  and  show  no  inclina- 
tion to  degeneration.  They  offer  a  uniform  resistance  to  the 
finger  on  palpation.  An  increase  of  mononuclear  leucocytes  with 
the  normal  total  of  leucocytes  points  to  pseudoleucasmia,  an 
increase  of  polynuclears  to  tuberculosis  (de  Renzi).  Now  and 
then  we  see  a  combination  of  pseudoleucasmia  with  tuberculosis 
of  the  lymph  glands,  as  shown  by  the  cases  of  Askanazy,  Waet- 
zoldt,  Weishaupt,  Cordua  and  MUller.  (See  also  Falkenheim, 
Sternberg,  Graetz,  Kirchner,  Lichtenstein,  Hoffmann,  Zuppinger 
and  others.) 

V.  Bergmann  mentions  the  possibilfty  of  mistaking  scrofulous 
neck  glands  for  atheromatous  cysts,  but  the  fact  that  the  latter  do 
not  appear  in  childhood,  and  that  if  they  appear  on  the  cheek  they 
grow  closely  into  the  skin  without  leaving  a  trace  of  inflammation, 
prevents  this  error.  We  need  hardly  take  into  consideration 
mistaking   a  branchial    cyst,   w^hich    invariably   lies   between   the 


DIAGNOSIS  245 

mastoid  jm-occss  and  the  liyoid  bone,  and  wliicli  arches  the  lower 
pari,  ol'  (lie  nioiilh  and  is  nev(;r  cfjnnected  with  skin;  or  a  partial 
li\|)cili(»|)li\  ol  ihc  li\(ii(l  qiand;  ilu-  latler  is  easily  recognized 
by  its  rising  and  falling  widi  ilie  niovemf;nls  of  swallowing 
(v.  Bergmann). 

For  die  dislinclion  of  scnjfulosis  from  syphilis,  (he  history, 
the  favourite  sites  tor  its  appearance,  the  special  signs  of  one  or 
other  disease  and  the  Wassermann  reaction  assist  us  in  forming 
an  opinion.  Mcjreover,  we  must  renifmix-r  diat  often  the  two 
diseases  co-exist. 

(2)  Bacteriological  Diagnosis. 

Proof  of  the  Tubercle  Bacillus. — Whenever  it  is  possible  an 
exact  diagnosis  should  be  based  on  the  demonstration  of  the 
tubercle  bacillus  either  by  the  usual  Ziehl-Neelson  staining  pro- 
cess or  by  inoculation  into  guinea-pigs  (see  Cornet,  "  Die  Tuber- 
culose,"  second  edition,  p.  715). 

The  introduction  of  antiformin  by  Uhlenhuth  in  examination 
for  tubercle  bacilli  was  of  great  importance  in  the  practical 
diagnosis  of  tuberculosis. 

Antiformin,  a  mixture  of  eau  de  Javelle  (liq.  sod.  hypochlor.) 
with  a  free  alkali  (i  litre  for  50  pfennigs — Osk.  Kuhn,  Berlin, 
Dirksenstrasse)  was  at  first  only  used  in  breweries  for  cleaning 
the  pipes,  on  account  of  its  property  of  dissolving  mucilage,  but 
was  shown  by  Uhlenhuth  and  Xylander  to  have  the  quality  of 
disintegrating  (in  a  solution  of  2  to  5  per  cent.)  most  bacteria,  the 
bacilli  of  cholera  and  typhus,  staphylococci  and  streptococci  with 
very  few  exceptions  (such  as  anthrax  spores)  in  at  least  2^  to  5 
minutes,  and  in  watery  solutions  to  kill  them  after  some  minutes, 
also  to  dissolve  mucus,  hair,  silk,  and  horny  substances  w-ithout 
leaving  a  trace  behind.  Wax  and  wool  are  not  dissolved  by  it  nor 
tubercle  bacilli,  and  the  acid-fast  bacilli  are  refractory  with  con- 
centrated solutions;  even  in  a  solution  of  15  to  20  per  cent,  their 
vitality  is  not  perceptibly  altered. 

Thus  a  means  was  discovered  of  freeing  sputum  and  other 
tuberculous  material,  parts  of  organs  and  f^ces  from  the  so-called 
accompanying  bacteria  and  of  rendering  them  suitable  for 
microscopic  examination  or  experiments  on  guinea-pigs  and  fo/ 
the  especially  difficult  cultivation  of  bacilli  from  sputum  (Uhlen- 
huth and  Xylander). 

Twenty  to  thirty  c.c.  sputum  and  15  c.c.  pure  antiformin  are 
made  up  to  100  c.c,  so  that  a  15  per  cent,  antiformin  sputum 
solution  results ;  after  two  to  five  hours  the  tinv  particles  are 
picked  out  or  centrifugalized  and  thoroughly  washed  in  a  solution 


246  SCKOFULOSIS 

of  slerilized  physiological  salt  soluiion  and  the  lillle  flakes 
inoculaird  inlo  glvcerine  serum  or  cxamim-d  as  they  are  (Uhlen- 
luiih  and  Kersien). 

Or  spuiuni  is  mixed  widi  ilir  same  \nilume  ot  water,  anli- 
formin  is  then  added,  so  tliat  a  25  per  cent,  soliiiion  of  sputum 
water  and  antiformin  is  obtained,  and  ihrn  it  is  well  shaken  to  a 
froth.  If  the  solution  is  of  a  brownish  colour  a  small  quantity 
of  antiformin  must  be  added  until  a  slightly  yellowish  colour  is 
obtained,  it  must  then  stand,  and  after  four  to  live  hours  the 
adherent  flakes  must  be  removed  by  shaking,  a  smear  of  the 
sediment  is  examined,  after  an  addition  of  sptilum  or  albumin 
water  (i  in  10)  to  make  it  more  consistent  (Gdrres).  The  process 
is  more  speedv  at  a  high  temperature — about  60°  C.  With  a 
strong  electric  centrifuge  the  segregation  can  be  considerably 
hastened. 

Besides  avoiding  disturbances  from  other  bacteria  and  from 
particles  of  tissue,  the  chief  advantage  of  this  method  is,  that  by 
the  use  of  antiformin  large  quantities  of  expectorated  matter  may 
be  concentrated  in  a  very  small  volume ;  for  example,  the  quantity 
of  sputum  ejected  in  one  day  may  be  so  concentrated  as  to  lie 
on  the  cover-glass  of  a  microscope  slide. 

The  antiformin  method  has  proved  itself  of  value  by  numerous 
tests  (Kriiger,  Hall,  Miinch,  Hoffmann,  Finkelstein,  Franken- 
burger  and  others).  As  a  source  of  error,  Beitzke  calls  attention 
to  the  presence  of  acid-fast  bacilli  in  the  water  from  the  main  ; 
Bren  has  found  them  in  distilled  water;  Schern  and  Dold  found, 
without  exception,  acid-fast  and  alkali-fast  bacilli  which  could  not 
be  distinguished  from  tubercle  bacilli  in  pipes  through  which 
water  had  run  for  a  long  time. 

Haserodt  combined  the  antiformin  method  with  that  intro- 
duced by  Lange  and  Nitsche,  viz.,  ligroin  admixture,  a  method 
which  has  also  proved  of  great  value,  especially  when  no  good 
centrifuge  is  at  hand  (v.  Scheven,  Skutetzky,  Herzfeld,  and 
Miinch);  Bernhardt  also  mentions  a  similar  antiformin-ligroin 
method. 

The  antiformin  method  modified  by  Lorenz,  by  boiling,  is 
very  simple  and  to  the  purpose;  2  to  10  c.c.  sputum  are  shaken  up 
with  two  or  three  times  the  quantity  of  15  per  cent,  antiformin 
for  H\-e  minutes,  till  it  becomes  a  homogeneous  mass,  which  is 
then  boiled  in  a  test-tube  and  centrifugalized  for  fifteen  minutes, 
the  whole  proceeding  taking  twenty  to  thirty  minutes. 

The  sediment  forms  fairly  w^ell,  larger  quantities  of  sputum 
are  first  treated  by  the  older  antiformin  method.  Lofiler  boils  the 
sputum  and   antiformin  mixture,   and   then  agitates   with   chloro- 


DIAGNOSIS  247 

form-alcohol  (10  grammes  :  1*5  grammes  eliloroform-alcoliol, 
10/90).  (Sec  Fabrici,  Iliine,  Koslovv,  Scliulle,  |'"rank,  Seemann, 
wSilvestri,   Weilii'.'ni'li  .'md  oiIhts.) 

A  "double  melliod  "  lor  (lie  conceni ral ion  of  the  luberclc 
bacillus,  described  by  I'^llerm.inn  .ind  I'j-landsen,  is  aulodigeslion 
of  (he  S|)ulum,*  cenlrifugali/.ing,  boiling  wiili  o'25  per  cent. 
sodium  hydrale  solution,  and  again  cenlrifugali/.ing;  this  cer- 
tainly is  attended  with  g(jod  resulls,  but  il  lakes  forly-(;igl)t  hours, 
causes  an  offensive  smell,  and  is  loo  i  roiiblesome  for  practical  use. 

Other  improved  methods,  ('.^'•.,  iliai  of  Zalin,  using  calcium 
chloride,  recommendfxl  by  Mende,  in  conjunclitm  with  anti- 
formin,  have  been  but  little  adopted. 

Much's  Granules. 

Much  made  the  assertion  that  in  tuberculous  tissue,  especially 
when  of  bovine  origin  and  in  caseated  glands,  where  it  is  often 
not  possible,  according  to  Ziehl,  to  demonstrate  bacilli,  a  form  of 
tubercle-virus  is  present  which  can  be  stained  by  Gram's  method, 
which  exhibits  itself  as  blue-black  granules,  either  isolated  or  in 
groups,  or  as  granulated  bacilli,  which  are  virulent  (Much's 
granular  form). 

Much  distinguishes :  (1)  Acid-fast  bacilli,  which  can  be 
stained  by  Ziehl 's  method;  (2)  non-acid-fast  bacilli;  (3)  granular 
form;  the  two  latter  can  be  stained  by  Gram's  method. 

Gram's  method  modified  by  Much  is  suitable  for  exhibiting 
them  as  follows  :  — 

(i)  A  thin  layer  of  the  material  laid  on  an  object-glass  is 
stained  with  methyl  violet  B.N.  (10  c.c.  of  an  alcoholic  solution 
in  100  c.c.  of  a  2  per  cent,  aqueous  solution  of  carbolic  acid) 
either  kept  twenty-four  or  forty-eight  hours  at  37°  or  boiled 
over  a  flame. 

(2)  Place  in  a  solution  of  potassium  iodide  one,  five,  or  ten 
minutes  (up  to  fifteen  minutes  according  to  Wirths). 

(3)  Wash  with  water. 

(4)  Place  in  5  per  cent,  nitric  acid  solution  for  one  minute. 

(5)  Place  in  3  per  cent,  hydrochloric  acid  solution  for  ten 
seconds. 

(6)  Decolorize  in  a  mixture  of  acetone  and  alcohol,  equal 
parts,  shaking  continually. 

(7)  Thoroughly  wash  with  water. 

These  researches  were  confirmed  by  Wirths,  \\>iss,  Deycke, 

*  With  half  a   volume  of  o'6  per  cent,    sodium   carbonate  solution,   at 
37°,   for  24  hours. 


24S  SCROFULOSIS 

Wolff,  W'elirli  and  Knoll,  Boas  and  Ditlcosen  (in  a  case  of  lupus) 
and  oihers,  and  Ziehl's  method  was  declared,  apparently  not 
without  jusiificaiion,  to  be  insufficient,  and  in  case  of  negative 
results  a  supplementary  test  by  Mtich's  method  was  recommended. 

Opinions  differ  as  to  the  nature  of  the  granules.  Much  con- 
siders them  to  be  a  vegetable  form,  Wirths  thinks  they  are  the 
most  virulent  form  of  bacilli  hitherto  known,  Schottmiiller,  Weiss, 
Pontes  and  others  express  the  same  opinion.  Schulz  considers 
ihem  to  be  a  resistant  form  deri\ed  frt)m  the  nnxious  iniluence  of 
immune  bodies,  which  remain  for  years  in  the  system,  and  with 
favourable  opportunity  may  again  produce  tuberculosis.  Here 
we  see  another  opportunity  of  adopting  the  most  far-reaching, 
speculative  decisions  upon  latency,  without  any  security  for  the 
foundation.  Knoll  looks  upon  them  as  spores,  but  Liebermeister 
will  not  accept  this. 

The  probability  is  that  we  have  to  do  with  products  of 
disintegration,  v.  Behring  has  also  expressed  this  opinion  by 
supposing  them  to  be  engendered  bacteriologically.  Geipel,  too, 
accepts  their  degenerative  nature. 

Spengler  claims  that  these  granules  of  Much  are  identical  with 
the  "  splinter  "  bacilli  mentioned  by  him,  as  does  also  Fuchs- 
Wolfring,  while  Much,  Wirths  and  Liebermeister  contest  this 
identity. 

The  appearance  of  such  granules  in  tuberculosis  has  been 
known  for  some  time  (see  Cornet,  "  Die  Tuberculose,"  second 
edition,  p.  24). 

As  other  granules  of  bacilli  as  well  as  cocci  stain  in  the 
same  way  by  Gram's  method,  a  conclusive  proof  of  INIuch's 
granules  is  impossible  in  all  cases  where  other  bacteria  cannot  be 
completely  excluded,  as,  for  example,  in  the  sputum.  Therefore 
the  claim  that  when  granules  are  found  this  alone  allows  of  a 
diagnosis  of  tuberculosis  is  all  the  more  hazardous,  because  with 
the  modified  Gram's  method  (Schottmiiller)  unavoidable  residue 
of  staining  material  and  such  like  may  easily  give  rise  to  mistakes. 

According  to  the  most  recent  researches  of  Bittrolff  and 
Momose,  of  the  Kossel  Institution,  all  these  findings  with  the 
far-reaching  conclusions  (Schulz  and  others)  come  dangerously 
near  to  being  upset,  for  according  to  them  no  different  form  is 
revealed  by  Much's  method  than  by  Ziehl's  method,  provided 
the  effect  of  the  staining  material  is  continued  for  the  same  length 
of  time  (twenty-four  hours).  Further,  when  by  Ziehl's  method 
the  result  is  negative  nothing  is  to  be  discovered  by  Much's 
method,  and  the  isolated  granules  which  appear  in  a  few  cases 
always  exhibit  acid-fast  constituents  on  restaining  by  Weiss's  or 
Ziehl's  method. 


DIA^NCJSJS  249 

'J'lio  melhod  of  Mullcr-J(jcliinann  and  Kcjlaczek  to  distinguish 
tuberculous  pus  from  oilier  |)us  (jn  tlif.  serum  f)laU:;  or  by  Millon's 
reagent  is  not  vei-y  appHcable,  on  account  of  ilie  frf()uent  mixed 
infection  in  the  pus  oi  scrofulcjus  glands. 

Endeavours  have  bc(Mi  made  to  ensure  the  diagnosis  of  lubf-r- 
culosis  by  opsonic  delerminaiioii,  biii,  lo  say  nothing  of  tlie 
troublesomeness  of  tiie  method  which  at  present  excludes  its 
application  in  practice,  it  appears  that  the  results  are  not  so  clear 
that  they  can  be  considered  valuabh;  diagnostically.  According 
to  Ilelmholz,  exudative  children  have  a  normal  or  increased 
opsonic  index,  lymphatic  and  scrofulous  children  a  low  index 
(see  also  Baecker  and  Laulj,  Noeggerath,  Kohlisch,  v.  Torday 
and  others). 

The  same  may  be  said  of  agglutination  tests,  according  to 
Arloing's  or  Koch's  method. 

Salge,  in  82  children,  amongst  which  were  71  infants,  had 
positive  serum  reaction  in  20  cases,  and  in  a  few  instances  this 
was  anatomically  confirmed,  in  others  not.     Schkarin  found  :  — 

(i)  Positive  agglutination  in  6  out  of  24  children  with 
symptoms  of  exudative  diathesis  (25  per  cent.). 

(2)  Positive  serum  reaction  in  25  out  of  41  children  with 
scrofulosis  (62"5  per  cent.). 

(3)  Fifteen  out  of  19  cases  of  tuberculosis  proved  clinically 
with  tuberculous  bones,  &c.  (78'9  per  cent.). 

(4)  Amongst  14  children  without  tuberculosis  clinically  3  were 
positive  (21  per  cent.). 

Noeggerath  obtained  agglutination  much  more  rarely  and 
considers  Schkarin's  findings  to  be  due  to  faults  in  experiments 
(see  Cornet,  "  Die  Tuberculose,"  second  edition,  pp.  720-724,  as 
well  as  the  abundant  literature  on  the  subject,  of  which  I  will 
only  mention  a  few  works  :  Comby,  Paganelli,  Miglio,  Brion, 
Ribas,  Kinghorn  and  Terichell,  Thomesco  and  Gra^oski,  Cozzo- 
lino,  Greco,  Calmette,  Gescheit,  Courmont,  Ferre  and  Saliger). 

For  the  present  the  fixation  of  the  complement,  the  serum 
deficiency  (owing  to  fatty  covering  of  the  bacilli),  or  Calmette 's 
snake  poison  reaction,  are  not  applicable  for  diagnosis. 

The  viscosity  of  the  blood  gives  no  con':'.'--'"ent  results  in 
tuberculosis.  According  to  Hess,  this  is  more  marked  in 
scrofulo-tuberculosis.  It  is  found  to  be  highly  valuable  in  miliary 
tuberculosis  and  in  tuberculous  bronchitis. 

To  hasten  the  result  in  inoculation  subcutaneously  in  the 
region  of  the  groins  of  guinea-pigs,  Bloch  has  at  the  same  time 
crushed  the  respective  inguinal  glands,  which  may  be  felt  between 
the  fingers  in  the  fold  of  the  groin,  and  w'as  able  after  about 
ten   to   fourteen  davs   to   demonstrate  a   considerable   quantitv   of 


250  SCROFLLOSIS 

bacilli.  l\anno\i(.s  aiui  Kapsaninicr,  Wolll-Misiu'i"  and  tuhers 
centirm  this  result  (see  also  Arth  and  Weber).  Scliern  and  Dold 
bv  combining  Bloch's  method  \vith  the  antiformin  method  have 
simplitied  and  hastened  the  proof  of  their  existence. 

Tuberculin  Diagnosis— Allergic  Reaction. 

The  C]uestion  of  the  tuberculous  nature  appeared  to  be  in  a 
few  cases  easily  sc^lved  when  v.  Pircjuei  introduced  his  well- 
known  cutaneous  or  allergic  test,  and  \\\)lif-h>isner  the  con- 
junctival reaction  in  the  diagnosis  of  tuberculosis.  Both  dis- 
coveries made  a  great  sensation  on  account  of  their  simple  and 
easy  mode  of  application,  and  hundreds  of  publications  and 
thousands  of  tests  followed,  the  results  of  which  did  not  entirely 
fulfil  the  great  hope  which  had  been  built  on  them,  but  still  they 
threw  important  accidental  lights  on  the  question  of  tuberculosis 
and  scrofulosis. 

The  significance  of  allergic  reaction  and  the  too  great  impor- 
tance which  has  often  been  attached  to  it,  and  the  erroneous 
conclusions  which  have  been  drawn  from  it  respecting  scrofulosis, 
make  it  necessary  to  go  into  it  thoroughly. 

V.  Pirquet  started  with  the  premise  that  an  organism  which 
has  gone  through  an  infection  changes  its  power  of  reaction  to 
the  same  causative  agent;  this  change,  the  so-called  allergic 
reaction,  is  seen  most  clearly  when  the  extract  is  inoculated  into 
the  skin. 

Everyone  who  is  capable  of  reaction  responds  to  an  infection 
bv  the  formation  of  antibodies,  the  immune  or,  more  properly,  the 
over-sensitive  person,  who  is  or  who  has  been  under  the  influence 
of  the  same  infection,  reacts  to  a  slighter  irritation  than  the 
healthy  person. 

According  to  v.  Pirquet  and  ^^'^assermann  the  reaction  itself 
is  explained  by  the  conjunction  of  the  anti-materials  formed  in  the 
body  (reaction  materials  according  to  Wolff-Eisner)  with  the 
tuberculin  which  has  been  introduced  (v.  Pirquet  and  Wasser- 
mann).  Up  to  this  point  the  tissue  cells  are  accustomed  to  create 
antibodies  under  the  influence  of  infection  ;  these  are  formed 
more  rapidly  and  intensively  from  the  action  of  the  fresh  infec- 
tion, as  the  body,  according  to  this,  possesses  a  greater  and  to 
a  certain  degree  a  more  educated  power  of  resistance  than  in  the 
beginning  of  the  illness,  and  in  advanced  cases,  by  reason  of 
successful  combating,  so  the  reaction  will  be  the  more  powerful 
according  to  the  more  intensive  formation  of  anti-materials;  with 
the  reduction  of  the  power  of  resistance,  the  more  the  disease 
advances  towards  a  fatal  endiuL;'  the  more  will   the  formation  of 


DIACiNOSIS  2-( 

anti-m<'il(M-i<'iI,  llic  rcaclioii,  become,  weaker  and  al  lasl  (Jisappear 
enlirely. 

In  lliis  sense  sligllL  rc.'aclinn  marks  iinlaxoiiiahir;  cases  aS  far 
as  prognosis  is  c(jiicerned.  'i  lie  liypersensitivcness  is  analogous 
to  lliat  which  occurs  in  animals  inUj  which  a  soruni  lias  bc-fMi 
injected  against  injection  of  iIk;  same  scrum. 

The  hypersensiliveness  is  referred  to  iIk;  effect  of  lysin  which 
sets  free  the  bacteria  which  have  been  inlroduc(;d,  and  makes 
them  innocuous  in  small  (|uanlilies  under  ilie  phenomena  of  hyper- 
sensitive reaction,  whilst  with  enlarged  (juantiti(;s  poisoning  lakes 
place  rapidly  owing  to  the  toxin  becoming  freed.  According 
to  this  the  non-tuberculous  person  does  not  react  because  he  has 
no  lysin  wliich  can  set  the  poison  free  from  the  debris  of  the 
bacilli  quickly  enough  (Wolff-Eisner  and  others).  These  hyper- 
sensitive reactions  are  not  only  found  in  the  tuberculous,  according 
to  V.  Pirquet,  but  similarly,  owing  to  the  same  toxin,  also  in 
leprosy,  glanders,  small-pox,  &c.  (Lemoire,  Parturier  and  others). 

When  only  later  inoculations  become  positive  we  may  sup- 
pose, according  to  v.  Pirquet,  that  there  were  no  antibodies  (to 
tuberculosis),  and  that  their  formation  was  only  demonstrated 
after  repeated  inoculations. 

By  repeated  inoculation,  antibodies  and  reaction  may  be 
induced  even  in  healthy  persons. 

Tlie  observation  tliat  rubbing  in  tuberculin  on  one  side  of 
the  body  will  sometimes  produce  redness  on  the  otlier  side,  often 
exactly  symmetrically,  and  that  nodules  will  appear  even  in  places 
far  distant  which  had  not  come  into  contact  wuth  the  tuberculin, 
leads  us  to  suspect  the  co-operation  of  nervous  influences. 

Moro  considers  from  this  that  the  percutaneous  tuberculin 
reaction  is  a  vasomotor  phenomenon  depending  on  strong  irrita- 
tion of  the  vasodilator  tracts,  an  angioneurotic  inflammation,  and 
refers  to  the  intimate  connection  of  tuberculosis  with  the  nervous 
system,  especially  with  the  sympathetic  nervous  svstem  (e.g., 
neuritis,  chronic  rheumatism,  liectic  flushes,  perspiration,  nervous 
disturbance  of- the  stomach  and  intestines,  and  disturbances  of 
menstruation,  &c.).  But  it  would  lead  us  too  far  to  go  further 
into  these  theories. 

Method  of  the  Proof  of  Allergie. 
V.  Pirquet's  Cutaneous  Method — The  inner  side  of  the  fore- 
arm is  carefully  cleansed  with  ether,  then,  at  a  distance  of  from 
6  to  lo  cm.,  place  a  drop  of  25  per  cent,  old  tubercuHn  (alt 
tuberculin  Koch,  and  5  per  cent,  carbol-glvcerine,  of  each  I'o, 
and  o'8  per  cent,   physiological  salt  solution   2"o),   then   scarifv 


252  SCROFULOSIS 

on  the  stretched  skin  between  the  two  drops  with  a  v.  l^irquet's 
chisel-shaped  inoculating  needle  or  a  line  lancet  as  a  place  of 
control,  and  in  the  drops  themselves ;  linally  a  piece  of  wool  is 
laid  over,  or  the  scarifications  are  simply  left  to  drv. 

In  about  live  to  twenty  hours  after  inoculation,  rarely  later, 
bright  red,  nodular  palpable  papules  of  from  3  to  20  mm.  in 
diameter  appear  in  tuberculous  persons,  now  and  then  streaks  of 
red  lines  radiate  from  the  place  of  inoculation.  Round  the  papule 
there  may  be  a  red  circle,  and  in  the  centre  of  the  papule  a  small 
blister.  The  patient  only  experiences  slight  pain  or  itching,  the 
reaction  is  apparently  purely  local ;  general  reaction,  fever,  as  well 
as  focal  reaction  are  as  a  rule  absent,  but  are  sometimes  observed 
(v.  Pirquet,  Peer,  and  Bayewsky). 

In  a  few  rare  cases  phlyctena^  have  appeared.  The  complete 
harmlessness  of  the  method  allows  of  its  application  even  \vith 
fever.  Reaction  phenomena  are  sometimes  delayed  for  live  days 
(late  reaction) ;  after  from  live  to  ten  days  the  papules  disappear 
altogether. 

V.  Pirquet  applies  the  term  torpid  to  a  reaction  appearing 
late;  now  and  then  a  positive  reaction  onh'  lakes  place  after  a 
second  test,  which,  according  to  Peer,  should  not  be  made  before 
the  eighth  day  at  the  earliest,  and  especially  in  cases  in  which 
there  is  no  clinical  evidence  of  tuberculosis,  but  it  is  only  demon- 
strated post-mortem  as  a  secondary  condition. 

The  degree  of  the  reaction  is  no  guide  to  the  extent  of  the 
tuberculous  process,  it  is  rather  the  reverse,  proportionate  to  the 
multipHcitv  of  the  foci  and  the  bacillary  dissemination  (Soltmann). 
Por  example,  in  the  cutaneous  test  the  greatest  reaction  is  found 
in  tuberculous  skin  lesions  which  are  generally  much  greater  than 
those  observed  in  pulmonar}^  tuberculosis  and  are  especially  weak 
in  the  atrophic  skin  of  the  cachectic  (Pfaundler,  Aloro  and 
Doganoff,  Eppenheim,  Bandler  and  Kreibich,  Doutrelepont  and 
Mainini).  Pure  undiluted  tuberculin  mav  be  used  with  equal 
success. 

Hv  simultaneous  application  of  various  c-oncentrations,  from 
I  to  50  per  cent.,  Erlandsen  and  Ellermann  sought  to  fix  that 
concentration  which  w-ould  establish  the  limit  which  just  gave 
demonstrable  traces  of  reaction  (tuberculin  standard  of  the 
organism),  the  measure  of  the  reactive  power  of  the  bodv.  TIt^ 
cutaneous  tests  with  5  to  10  per  cent.' prove  to  be  of  equal  value 
with  the  conjunctival  test  and  injection  ;  ac.-ording  to  Gotsche 
and  Petersen  the  i  per  cent,  solution  in  adults  generally  indicated 
only  active  tuberculosis,  Alirauer  considers  the  graduated  method 
practicable,  Lossen  and  Moller  consider  it  uncertain. 


niACNosis  253 

I  lislological  cxamin.'il  ion  of  excised  papules  shows  nodular 
inassinj^"  of  epidu'lioid  cells,  p,-iiil\  siinoimded  Wy  a  zonf  ol  roun(J 
cells,  llie  lypical  i^i.'inl  cells  ol  Lnnghans,  and  distended  capil- 
laries; the  picture  (j1'  lypical  tubercles  without  caseation,  clianges 
such  as  are  caused  by  toxins  and  by  material  capable  of  diffusion 
given  off  by  the  lubercle  bacilli  (Zieler  v.  Wolff-Eisner,  Handler 
and  Kroibich,  Pick,  Daels,  Aronnde  and  Falk). 

Modification  of  v.  Pirquct's  Method. 

Intimate  contact  with  the  uninjured  skin  by  tuberculin  or  dead 
bacilli  with  friction  suflices  to  cause  cutaneous  reaction  (Lignieres 
and  Berger,  Naegeli-Akcrblom  and  Vernier)  or  pressure  (Siegert 
and  Barabaschi). 

Ointment  Reaction.— iMoro  (and  Senger  independently)  j:)ro- 
duced  reaction  bv  friction  ^\ith  a  tuberculin  ointment  on  the 
uninjured  skin. 

Method  of  Using  Moro's  Ointment. — A  portion  of  tuberculin 
ointment,*  the  size  of  a  pea  (tuberculin  with  equal  part  of 
anhydrous  lanoline,  the  latter  to  be  warmed  to  20°  to  30°  before 
mixing)  is  rubbed  for  half  to  five  minutes  on  the  abdomen  or 
chest  over  a  place  5  cm.  square,  which  is  then  left  uncovered  for 
ten  minutes;  a  protective  bandage  is  unnecessary;  this  method 
has  the  advantage  of  remarkable  simplicity  and  of  not  attracting 
the  attention  of  nervous  patients ;  the  ointment  has  the  advantage 
of  keeping  for  months  in  an  ice-chest. 

Moro  has  obtained  a  similar  result  with  a  loosely-adhering 
tuberculin  plaster;  Piesen  recommends  a  50  per  cent,  tuberculin- 
glycerine. 

The  ointment  reaction  declares  itself  either  as  :  — 

(i)  Weak;  after  24  to  28  hours  (seldom  later)  2  to  10  distinct 
reddened  nodules  appear  of  i  to  2f  mm.  diameter,  which  disap- 
pear after  a  few  days  w-ithout  itching. 

(2)  Medium ;  in  the  course  of  24  hours  many  (up  to  a  hundred 
or  more)  nodules,  of  3  mm.  diameter,  spring  up  and  remain  for 
several  days  with  slight  itching. 

(3)  Severe;  after  a  few  hours  100  and  more  nodules  appear 
of  5  to  8  mm.  diameter  with  itching  and  exudation,  and  spread 
over  the  adjacent  skin.  After  a  few  days  the  papular  efflore- 
scences dry  up,  scale  off,  and  after  a  couple  of  weeks  leave  behind 
a  brownish  pigment. 

On  the  site  of  reaction   a  typical  lichen   scrofulosorum   has 

*  To  be  had  in   small  tubes   of  7  grammes  for  20  reactions  from  the 
Crown  Pharmacy,   JNIunich. 


254  SCROFLLOSIS 

several  limes  appeared  subsecjuenily,  al  either  limes  a  iransilury 
general  exanthem  or  an  erythema  nodosum  ;  bui  once  long- 
standing lichen  scrofulosorum  disappeared  leaving  no  trace. 

Symmetrical  reaction  on  the  opposite  side  and  disseminaleil 
distant  reaction  has  been  mentioned  above  (p.  231)  (Mori)  and 
Bullinger);  now  and  then,  especially  with  the  atrophic  skin  of 
older  persons  suspected  of  tuberculosis,  positive  reaction  is  only 
Libtaincd  after  two  severe  frictions. 

Further  Modifications  of  Allergic  Reaction 

Buschke  and  Kuttner  laid  on  the  skin  a  cantharides  plaster 
^  cm.  stjuare,  and  injected  into  the  resulting  blister  25  per  cent, 
old  tuberculin;  the  results,  according  to  their  statements,  are 
more  exact  than  by  v.  Pirquet's  method. 

Intradermic  Reaction. — Moussu  and  Alantoux  injected  into 
the  skin  a  drop  of  tuberculin  solution  i  :5000  {=^jlomg-),  and  with 
children  who  did  not  react  to  this  i  :  100.  Most  of  the  children 
exhibited  redness  and  some  infiltration  after  this,  which  reached 
its  maximum  about  forty-eight  hours  later,  and  after  a  further 
fortv-eight  hours  disappeared,  whilst  the  true  intradermic  reaction 
onlv  appears  on  the  second  day.  This  method  is  recommended 
bv  Mac  de  Lepinav,  Boncli  and  others  as  rather  preferable  to  the 
cutaneous  test. 

Romer  emploved  it  in  animals  which,  on  account  of  reduced 
skin  absorption  ( ?),  were  often  insusceptible  to  the  cutaneous  test, 
and  found  the  results  equal  in  value  to  subcutaneous  injection 
(Romer  and  Joseph,  Kraus  and  Volk). 

Tedeschi  preferred  the  injection  (of  jhr,  mg.)  into  the  skin 
of  the  horizontal  portion  of  the  auricle.  Monti  objects  to  this 
auricular  test  because  it  induces  deformity  and  swelling  of  the 
glands. 

Streak  Reaction. — Epstein  and  Escherich  had  already  observed 
in  tlie  nineties  that  after  tuberculin  injections  in  the  tul^erculous  a 
characteristic  inflammation  appeared  at  the  site  of  injection.  From 
this  observation  Reuschel  and  Hamburger  recently  further 
improved  the  method  of  streak  reaction  :  o'l  to  o'2  or  even  i  mg. 
is  injected  into  the  upper  arm,  being  doses  which,  t\vo  or  three 
days  after  the  cutaneous  reaction,  and  before  tuberculin  sensibility 
is  increased,  can  generally  be  borne  without  fever.  As  a  reaction 
after  twenty-four  hours,  not  only  the  usual  pink  or  livid  circle  is 
exhibited,  but  in  tuberculous  persons  a  circumscribed  inflam- 
mation starting  from  the  subcutaneous  tissue,  with  oedema  and 
pain  on  being  touched,   which  continues  four  to  five  days.     By 


1)IA(,.\().SI.S  255 

this  mcllxxl  aclivc  foci  arc  (;onrii)ii(:(J  vvlicii  ihc  culanciju.s  LcsL  fails 
(see  also  vScliick,  (iriincr  and  ollicrs). 

'riic  obscrvalion  ol  A  rxonadc  and  \-:\\k  is  wnrlli  menlionin^^ 
If  nol  less  llian  IvvcUc;  lionis  aflcr  ;i  \.  IMr()iicL  inoculation  a 
(()iii"ni((ucl  (ir  a  sncliim  ;i|)|).ii.-iiiis  he  pl.'K  cd  on  \\\c  inoculated  arm, 
after  a  few  minutes  to  a  (juarter  of  an  hour  small  luemfjrrliages 
occur  on  the  reacting  papiiU'S,  and  p.nily  also  in  plac(\s  Avliicli 
had  not  reacted  before,  bni  ikmic  .-ippcir  on  ilic  site  of  control. 
Ointment  and  streak  reactions  (see  bchjvv)  behave  in  the  same  way. 
The  lucmorrhages  are  valuable  also  in  cases  of  doubtful  reaction, 
and  will  appear  six  weeks  after  the  inoculation. 

Wolff-Eisner's  Conjunctival  (Ophthalmic)  Reaction. — Immf- 
diately  following  on  v.  Pirquet's  demonstration  of  his  cutaneous 
test  in  the  Berlin  Medical  Society,  Wolff-Eisner  communicated 
his  conjunctival  test.  His  method  is  as  follows  :  A  drop  of  sterile 
|- to  I  per  cent,  solution  of  old  tuberculin  (the  best  is  "  tuberculin 
for  ophthalmic  reaction  Ruete-Enoch  ")  is  introduced  into  the 
inner  angle  of  the  eye  whilst  the  patient  looks  up. 

By  drawing  down  the  lower  lid  the  solution  is  prevented  from 
being  forced  out  by  the  closing  of  the  lids.  The  result  takes  place 
after  twelve,  twenty,  or  forty  hours. 

Following  the  example  of  INIoro,  Wolff-Eisner  recommends  a 
I  to  2  per  cent,  tuberculin  vaseline  for  the  ophthalmic  test  instead 
of  the  fluid  tuberculin. 

Conjunctival  reaction  shows  itself  after  three  or  four  hours, 
sometimes  only  after  fifteen  hours,  and  even  after  twentv-four 
hours,  by  slight  redness  and  injection  of  the  under  lid,  with  swell- 
ing of  the  lachrymal  caruncle,  and  there  is  enlargement  of  the 
pupil  which  may  also  occur  in  non-reacting  patients. 

In  more  severe  reaction  swelling  of  the  follicles  and  a  flow  of 
tears  appear;  the  ocular  conjunctiva  and  the  sclerotic  are  also 
affected,  or  a  fibrinous  or  suppurative  secretion  is  seen,  with 
oede'ma  of  the  lid  and  ecchymosis ;  subjectively  the  reaction  shows 
itself  by  the  sensation  of  a  foreign  body  or  a  slightlv  stretched 
feeling,  heat  in  the  eve,  itching  and  pain. 

A  general  reaction  is  only  exceptionallv  observed  (Andeoud, 
Schroder,  Kaufmann). 

When,  with  suspicion  of  tuberculosis,  the  conjunctival 
test  gives  a  negative  result,  a  repetition  of  the  test  twentv-four 
hours  later  (according  to  WolfT-Eisner).  or  four  davs  (according 
to  Erlandsen)  should  be  undertaken  with  2  per  cent,  tuberculin  in 
the  other  eye,  and  at  the  same  time  supplemented  bv  a  cutaneous 
or  streak  test ;  this  has  then  frequentlv  led  to  positive  results 
(WollT-Eisner  and  Brandenstein,  Evre,  Wedd  and  Hertz.  Baldwin 


256  SCROFULOSIS 

and  Lacke).  The  cHjnjunniNal  rcaciion  was  lirsi  cunlirniecl  on 
tuberculous  cattle  by  Vallee,  bui  he  warned  again.si  its  use  on 
man  on  account  oi  the  se\-ere  eye  syniplonis;  it  was  ihen  le-tesled 
bv  C'almelle,  and  therefore  sometimes  described  wrongly  as 
Calmelle's  reaction,  ihen  by  LeluUe,  Dufour  and  Comby  and  Jean 
Lepine,  and  in  Germany  tirst  re-tested  by  Citron,  Eppenheim, 
Schenlv  and  Seiffert,  Kohn,  Fr.  Levy  and  others,  whereupon  a 
deluge  of  researches  were  made  respecting  the  utility  of  the 
method. 

Unforiunateh-,  ii  is  not  so  harmless  as  one  might  believe  from 
Wolff-I'^isner,  Schenk  and  Seiffert,  Clark,  Umber  and  others. 
Corresponding  with  Vallee's  experiments  on  animals  after  the 
eye  test,  severe  and  serious  eye  changes  were  soon  observed  in 
man  also,  which  continued  for  months,  and  often  resembled  the 
phenomena  which  frequently  appear  in  scrofulous  persons.  There 
occurred  verv  severe  keratitis  (Barbier),  corneal  opacity,  acute 
blennorrhoea,  with  chemosis  (Plehn),  eczematous  conjunctivitis 
(Damask),  formation  of  ulcers  (Butler),  permanent  disturbance  of 
vision  (Polland),  ten  to  twenty  days  later,  superficial  corneal 
ulceration  (Lapersonne),  (see  also  Pfaundler,  Peer,  Trousseau. 
Wiens  and  Giinther,  Eppenheim,  Klieneberger,  Buch,  Boral, 
Seligmann,  Schrumpf,  Satterlee  Woodcock,  Siegenbeck  van 
Heukelom,  Collin,  Danielopulo). 

A  repetition  in  the  same  eve  (Eppenheim,  Schenk  and  Seiffert 
and  others)  is  to  be  avoided  on  account  of  increased  irritative 
symptoms  (Stadelmann,  Klieneberger  and  Plehn)  wdiich  occur 
even  in  health v  subjects,  not  to  mention  the  un'reliabilitv,  for  if 
repeated  within  eight  weeks  (Goebel)  we  get  positive  results  even 
with  clinically  unsuspected  persons  (78  per  cent.)  (Klienel^erger, 
S.  Cohn,  F.  Lev}',  Micheli,  Bing,  Goebel). 

The  severe  injury  may  be  due  partly  to  the  employment  of 
stale,  chemically  changed  solutions  (Schenk,  Steindorff,  Fabian 
and  Knopf)  or  too  strong  preparations,  especially  the  Hocl'ster 
preparation  (Wiens  and  Giinther,  Krause  and  Hertel,  Treupel, 
Citron  and  others),  but  also  to  Calmette's  solution  (Goerlich). 

Still  the  fault  of  the  injury  to  the  eye  does  not  lie  in  the 
preparation  alone,  as  sometimes  even  with  the  employment  of  the 
innocuous  i  per  cent,  old  tuberculin  seriously  severe  reaction 
occurs  (Collin  and  others),  therefore  the  conjunctival  test  must  be 
absolutely  avoided,  not  only  in  tuberculous  (scrofulous)  eye 
diseases  which  may  easily  be  intensified,  but  also  in  all  other 
affections,  even  in  simple  irritative  condition  of  the  other  eye 
(Adam,  Citron,  Eisen,  Siegrist  and  others). 

Reaction  in  other  Mucous  Membranes. — Lafitte,  Dupont  and 


l)iAON(;si.s  257 

Mouliiiici-  have  iiil  i<  idiiccd  a  1  [jva  cciiL.  LaliiK-Llc'b  .soliilioii  by 
means  ol  wadding  inio  the  sei^Lum  nasi  and  (observed  exudation. 
I'oll.'K  i  induced  reacLi(jn  in  the  muajus  membrane  o(  llie  moulli, 
Oppenlicini  in  (he  un'llira.  VVinldcr  mentions  skin  reacticjn  alter 
electrolytic  inlroduclion  ol  old  iiiberculin,  and  Sahj  observed 
fever  amounting  to  3<S'5'^  C".  m  1  iibciciiloiis  patients  on  internal 
administration  of  'ooi  c.c.  old  tuberculin,  whilst,  according  to 
Pfeifler  and  Seyacker,  the  internal  tuberculin  preparations  usually 
sold  produce  no  fever  even  in  large  doses.  Hell  obtain(,-d  similar 
results. 

Results  of  Allergje  Reaction. — After  thousands  of  tr-sis  ii  lias 
been  confirmed  that,  as  a  rule,  positive  reaction  takes  place  by  the 
methods  mentioned  in  cases  clinically  proved  to  be  tuberculosis. 

As  all  the  methods  based  on  allergic  do  not  differ  in  principle, 
the  hypotheses  and  results  are  the  same  for  the  one  as  the  other, 
and  tile  differences  are  more  (juantitative  than  qualitative. 

The  specific  character  of  the  reaction  is  contested  by  the 
statement  that  positive  reaction  also  occurs  in  other  diseases  that 
form  vaso-dilator  toxins  (see  Arloing,  Purjesz,  Entz,  Xaegeli- 
Ackerblom  and  Vernier,  Tezner  and  Schmidt-Nothmann),  but 
even  if  the  strictly  specific  character  suffers  a  certain  restriction,  yet 
there  is  a  difiference  between  that  apparent  reaction  and  genuine 
Iiiberculin  reaction,  which  hardly  allows  the  specific  nature  of  the 
latter  to  be  contested. 

A. — Clinical  Tuberculosis. — v.  Pirquet  found  conformity 
in  200  cases  which  were  proved  b\-  posl-mortem,  64  with  positive 
reaction,  and  109  with  negative  reaction.  Amongst  Peer's  344 
cases,  of  25  with  clinical  tuberculosis,  24  reacted  positively ;  of  28 
suspected  cases  14  were  positive;  of  291  not  suspected  cases  27 
(9  per  cent.)  were  positive;  of  112  infants,  3  were  positive  (con- 
firmed by  autopsy)  (see  Kreibich,  Engel  and  Bauer,  Schleisner, 
Goebel  and  Peschorner  (769  cases)  and  others). 

Positive  reaction  in  tuberculosis  is  unanimously  confirmed 
with  but  few  exceptions. 

NectAtive  Reaction  in  Tuberculous  Persons. — Negative 
reaction,  in  spite  of  demonstrated  tuberculosis,  is  observed  in 
very  advanced  cases,  in  miliary  tuberculosis  (Kietz,  Goebel 
negative,  Aronade  and  Falk  positive),  in  persons  who  have  shortlv 
before  undergone  tuberculin  treatment  and  have  had  a  large 
quantity  of  tuberculin,  in  cachectic  and  carcinomatous  patients 
(Roily)  when  the  power  of  resistance  is  paralysed,  and  antibodies 
are  not  formed  in  sufRcicni  quantities. 

The  behaviour  in   measles  is  very  important.      One  or  two 

17 


258  SCROFLLOSIS 

days  before  the  appearance  of  the  exanthem  of  measles  even 
tuberculous  cliiklrcn  lose  the  power  of  reacting  for  about  a  week, 
and  thai  so  regularly  ihal  positive  reaction  would  point  diagnostic- 
ally  against  measles  (Preisich,  v.  Pirquet  and  others).  Suscepli- 
biliiv  10  tuberculin  is,  according  to  Gruner,  reduced  nearly  1,000 
times,  but  is  restored  t)n  a  rapidly  increasing  scale  at  about  I  lie 
eighth  day  after  the  outbreak  of  the  exanthem.  It  has  been  sought 
to  prove  in  this  phenomenon  the  defencelessness  of  a  patient 
suffering  from  measles  against  the  poison  of  tubercle  bacilli,  and 
an  analogy  to  the  reduction  of  vaccine  streak  reaction  (Hamburger 
and  Schey),  a  rrthuiion  of  llie  "  energv  "  of  the  body  which,  as 
a  sort  of  antibod\-,  brings  about  the  reaction  between  tuberculin 
and  the  cells  which,  owing  to  the  measles,  is  cut  off  (v.  Pirquet). 
Reaction  frequently  proves  negative  in  the  incubation  stage 
of  scarlet  fever  (Brandenberg).  In  forty-six  scarlet  fever  patients 
only  eight  reacted  positively  in  the  exanthematous  stage,  but 
twenty-six  of  the  negative  cases  gave  positive  results  when  con- 
valescent. 

On  the  other  hand,  reaction  papules  which  have  disappeared 
for  weeks  may  again  appear  with  an  outbreak  of  the  rash  of  scarlet 
fever  or  measles  (Heim  and  John-Schick). 

In  thirty-three  cases,  in  the  fever  stage  of  croupous  pneu- 
monia, fifteen  showed  a  positive  reaction,  eighteen  a  negative 
reaction.  But  of  the  latter  eleven  when  con\alescent  showed  a 
positive  reaction  (Roily). 

In  acute  serous  pleurisy  Barbieri  found  the  cutaneous  reaction 
almost  always  negative. 

The  ointment  and  cutaneous  reaction  was  also  positive  in  a 
series  of  cases  in  which  there  was  no  suspicion  of  tuberculosis, 
but  in  which  purpura,  epilepsy,  chorea,  herpes,  or  hvsteria  were 
present.  "  Absolute  reliability  "  (Germonig,  of  Trieste,  and 
others)  is  not  obtained  by  this  method. 

In  typhus,  in  spite  of  there  being  no  tuberculosis  (as  shown 
by  autopsy),  reaction  is  not  rarely  positive  (Bourget,  S.  Colin, 
Krokiewicz,  Calmette,  Fabian  and  Knopf,  Nestor  and  Bar- 
buneanu),  and  tuberculous  patients  react  interchangeablv  to 
typhus  and  extract  of  Bacillus  coli  coiuiuunis  (Krauss,  Lusen- 
berger,  aru.1  Russ).  Inil  (lie  course  of  this  reaction  is  much  more 
speedy  and  \'iolent  ih;in  in  the  |:)Ln-elv  luberculous  (C'dlin  ;  sec  also 
Chantemesse,  Bhini  ant!  Sclilippe). 

In  syphilitics  who  were  free  from  tuberculosis,  Nicolaus, 
Fa\re  and  Charlet  generally  found  distinct  positive  reaction. 

In  acute  articular  rheumatism  a  positive  reaction  is  found 
relati'/eh'   often    (Schenk  and   Seiffert,    Colin   and    Krokicwic-z,    in 


I)IA(;n(;.sis  259 

50  |)('r  ccni.);  l'\-i.|)ian  ami  Kiiopl,  mi  iIk-  <  oiii  rary,  always  touiul 
it  n(;galivc. 

13. — Clinjcal  Siisi'i'icis.-  In  persons  wlio  arc;  suspected  of 
tuberculosis  (lu;  culancous  reaction  \rry  trc(|U(;ntly  gives  positive 
results,  which  have  been  conlirmed  by  ihc  later  course  of  the 
disease  or  by  'post-mortem  examinaiion. 

C. — Clinically  I'ki:I';  iko.m  'I  i;m;K(  i;l(;sis.  Lasily,  in  those 
persons  who,  clinically,  give  no  sign  of  tuberculosis,  cutaneous 
rcciction,  as  a  rule,  is  wanting  in  infancy  and  early  childhood; 
almost  complete  agreement  exists  between  the  reariif)n  anrl  ilif 
clinical  findings  or  the  posl-mortem  result. 

Corresponding  to  the  rarity  of  tuberculosis  in  the  first  six 
months  of  life,  at  this  age  in  all  tests  reaction  is  rarely  positive; 
with  increase  of  age  in  the  person  examined,  a  pcjsitive  reaction 
is  observed  with  increasing  frequency  without  any  definite  clinical 
causation. 

Positive  results^  were  obtainc^d  l)\'  :  — 

V.    PiRQUKT  IN   Vienna. 

1  year      ...  ...    ...    ...    ...    ...    ...   7  per  cent. 

1  to  2  years  ...    ...    ...    ...    ...    ...  24 

2  to  4   ,,  Z7 

4  to  6   ,,  53 

6  to  0   ,,  57 

10  to  14   ,,  ...    ...    ...    ...    ...    ...  68 

Engel  and  Bauer  in  Dusseldorf. 

3  to  4  years  ...         ...         ...     i6'5  per  cent,  positive  v.   Pirquet 

,    5  to  6       ,,  i6'6         ,, 

7  to  8       ,,  30-2 

9  to  10       ,,  49 

1 1  to  12        ,,  ...  ...  •••35  ,, 

13  to  14       ,,  S3  ,, 

NOTHMAXN. 

3  to  5  years  ...                     ...  47      per  cent,  positive  v.   Pirquet 

6  to  7  ,,  56 

8  to  g  ,,  ...         ...         ...  7o'7 

10  to  I  I  ,,  ...          ...          ...  81 

i^i  to  14  ,,  84-5 

The  supposition  is,  that  in  cases  wherever  clinical  svmptoms 
are  lacking,  and  where  the  positive  reaction  did  not  appear  at  the 
tirst  time  of  observation,  the  positive  reaction  was  caused  bv  tuber- 
culosis, either  latent  or  inacti\e,  ttr  which  has  become  arrested. 

^  Mantoux  and  Lemaire  found  amongst  poor  children  who  reacted  to 
tuberculin  16  per  cent,  in  i  to  2  years  of  age,  51  per  cent,  in  2  to  4.  66  per 

cent,  in  3  to  4,  and  84  per  rent,  in  7  to  15  years  of  age. 


260  SCROFULOSIS 

This  is  very  frequently  confirmed  by  the  post-mortem  findings. 
In  many  cases,  however,  of  positive  reaction  atitopsy  shows  no 
trace  of  tuberculosis,  and  it  is  then  a  question  whether  small 
tuberculous  lesions  have  been  overlooked  in  examination,  or 
whether  former,  tuberculosis  has  completely  healed,  leaving  no 
visible  trace,  as  in  variola  (Knopfelmacher  and  others),  where  it 
has  been  observed  that  the  signs  of  allergie  have  been  for  a  long 
time  suppressed,  or  whether  the  cutaneous  reaction  (see  above) 
can  under  certain  circunislances  occtir  withoiii  iiiberctilous 
antecedents. 

In  any  case,  the  cutaneous  lest  is  an  extraordinarily  delicate 
test,  capable  of  indicating  not  only  active,  but  also  completely 
inactive  foci,  those  produced  either  by  the  bovine  bacilli  (a  species 
foreign  to  the  bodv),  which,  as  a  rule,  are  advancing  to  their 
spontaneous  in\n)lution,  or  foci,  whether  of  bovine  or  human 
origin,  which  are  already  calciiied  or  completely  healed.  But 
practical  utility  suiYers  a  severe  loss  from  this  fact,  as,  although 
inactive  foci  certainly  interest  us  from  the  point  of  view  of  morbid 
anatomy,  they  only  to  a  certain  degree  engage  our  clinical  interest, 
and  in  no  way  indicate  the  lines  of  treatment. 

As  such  clinically  unimportant  foci  appear  much  more 
frequently  with  ad\'ancing  years,  and  always  oftener  in  adults,  a 
cutaneous  reaction  is  almost  valueless  for  adults  and  even  for  later 
youth,  but  retains  its  importance  for  early  childhood,  and  also  for 
the  scrofulous  in  a  certain  sense. 

Moro's  ointment  is  somewhat  less  sensitive  than  v.  Pirquet's 
method,  but  at  the  same  time  it  also  shows  inactive  foci,  and  is 
therefore  of  little  value  for  adults  (Emmerich  and  others).  W^ith 
children  it  indicates  active  foci,  with  perhaps  more  probability 
(Moro  and  Doganoff,  Lignieres  and  Berger,  Lantier,  Naegeli- 
Akerblom  and  Vernier,  Kanitz  and  others;  Wetzell  has  221 
cases),  but  it  tells  us  nothing  of  the  origin  of  the  bacillus  or  its 
virulence. 

Monti's  comparative  researches  on  300  children  gave  results 
as  follows  :  — 

According  to  Moro        According  to  v.  Pirquet 

In  certain  tuberculosis  ...  88  per  cent.  ...  q8  per  cent,  positive  reaction 
Persons     suspected     of 

tuberculosis  ...     65  ,,  ...     78  ,, 

Apparently  free  from 

tuberculosis  •••34  ,,  •••44  ,, 

Emmerich  found  that  of  clinically  non-suspected  persons, 
according  to  Moro  ^2  per  cent.,  and  according  to  v.  Pirquet  79  per 
cent,  reacted. 


DfAfiNOSIS  261 

Conjuncliv.'il  rend  ion  li.'is  pioNcd  iis'-lf  less  sensitive  than  the 
V.   Pir(|ii(*l  's  niclhod. 

JVloiV'lli  loiind  ;iiii()nysl  300  arhilis  in  :  — 

According 
.\i;t.or(liiiK  10  l'iri|iit;t  to  Wolff-Kidner 

I  14    persons  will)   |)iil  inoii;i  ly 

tuberculosis  ...  oS  ])cr  cent,  positivr;  rf.'irtion   86  per  cent. 

22   i^crsons  with  olhcr  forms  of 

tuberculosis  ...  yi         ,,  63         ,, 

68  tuberculous   suspects  ...  49         ,,  47         ,, 

(/)  tuberculous  non-suspects  21  ,,  11  ,, 

A  compilalion  of  S(lir(Klcr  and  Kanfniann  ^^'lV(•,  inchisivc  of 
the  severest  cases,  {positive  reactions  in  .S55  per  cent,  amongst 
971  tuberculous  persons;  51 '4  per  cent,  amongst  284  suspects; 
I2'7  per  cent,  amongst  627  persons  clinicalK'  not  tuberculous, 
and  C'ahnelte  mentions  over  14,000  observations  b\'  clinicians  of 
all  countries,  according  to  whom  92  per  cent,  in  advanced  tuber- 
culous patients,  and  61  per  cent,  of  suspects,  and  18  per  cent,  of 
apparenth-  non-tuberculous  gave  a  positi^•e  result. 

Wolff-Eisner's  statement  that  his  method  only  revealed  active 
foci,  that  healed  lesions  were  revealed  by  late  reaction,  and  the 
inactive  only  by  repetition  has,  unfortunatelv,  not  been  confirmed. 

The  following  exaniples  prove  how  far  opinions  differ  respect- 
ing the  conjunctival  test  :  — 

Some  authors  recommend  it,  emphasize  its  great  importance 
and  reliability  (Schenk  and  Seiffert,  Schubert,  Boyd,  Malmstrom, 
Megias  (120  cases),  Parker,  Bjelilowski,  Pons  y  Marquez),  or  they 
praise  its  value  for  the  period  of  childhood  (Combv,  Peer,  Siegen- 
beck  van  Heukelom),  or  they  note  its  value  for  special  regions, 
for  affections  of  the  ears  and  larynx  (Wilzcur),  or  for  skin 
affections  (Sequeira). 

On  the  other  hand,  some  authors  object  to  its  verv  restricted 
reliability  (Wiens  and  Giinther  (409  cases),  Fehsenfeld,  Tice, 
Kohler  and  Burg). 

Lastly,  many  authors  object  to  it  entirely,  or  at  least  warn 
against  its  employment  (MoUer,  Collin,  Purjesz,  Daniels,  Schloss- 
mann and  others). 

Siegrist  considers  it  of  little  value  for  the  eye  specialist,  and 
dangerous  for  persons  suffering  from  aft'ections  of  the  eves ; 
Zoppritz  denies  its  value  for  discharging  and  open  tuberculosis. 

According  to  Calmette,  Calzolani,  Lurie-Liidke,  Fabian  and 
Knopf,  the  positive  result  points  with  certaintv  or  probabilitv  to 
fresh  tuberculosis,  excepting  in  typhus  fever  (Damask),  to  active 
tuberculosis  according  to  Tobiescu,  whilst  Coderque  does  not 
accept  positive  reaction  as  a  sign  of  active  tuberculosis,  for  foci 


262  SCROFULOSIS 

which  ha\e  run  tlieir  ciuirse  read  posili\ely,  and  Baldwin  only 
considers  it  conclusive  when  reaction  appears  speedily  with  small 
doses. 

Negative  reaction  naturally  does  not  exclude  tuberculosis, 
with  the  exceptions  already  mentioned  under  the  head  of  cutaneous 
reaction,  l)ut  makes  it  otherwise  improbable  (Calmette,  Fabian 
and  Knopf,  M.  Eisasser  and  Liidke,  Hormann,  Schroder  and 
Kaufmann,  and  Medowikoff) ;  from  oiIut  (luarters  negative 
reaction  is  denied  any  importance  at  all. 

.\s  [o  the  general  applicabilii\'  of  the  allergic  test,  we  come 
lo  ilic  conclusion  that  it  has  no  absolute  reliability,  Ijut  is  of  value 
as  a  means  of  supporting  the  diagnosis,  that  the  positive  cutaneous 
test  is  capable  of  proving  with  the  greatest  trustworthiness  a 
tuberculous  focus  of  any  sort,  cictive,  inactive  or  healed,  of  human 
or  bovine  nature,  with  the  above-mentioned  limitations,  but  that 
its  diagnostic  value,  as  v.  Pirquet  himself  has  stated,  is  limited 
to  the  early  years  of  childhood  (according  to  Calmette  to  the  first 
three  vears,  to  Briickner  to  the  fifth  year,  to  Cioebel  to  the  twelfth 
vear).  'I'he  younger  the  child,  the  nearer  it  is  to  infancy  the  more 
reliable  is  the  cutaneous  test;  according  to  general  opinion  (Peer, 
Briining,  Goebel,  Briickner  and  others),  it  appears  to  be  specially 
valuable  in  infants  when  tuberculosis  is  concealed  under  the 
appearance  of  atrophv,  because  at  this  age  inactive  foci  practically 
never  appear. 

A  negative  result  in  older  children  and  adults  (more  important 
than  the  positive  result  (Peer  and  Makowski)  excludes  with  all 
probability  the  presence  of  tuberculosis  unless  we  have  to  do  with 
advanced  tuberculosis,  miliary  tuberculosis  with  preceding  tuber- 
culin treatment,  with  marasmic  and  cachectic  persons,  or  with  a 
patient  suffering  from  measles,  especially  in  cases  in  which  it  is 
repeated  with  the  above-mentioned  limitations  (J.  Beck  in  808 
cases,  and  amongst  adults,  Goebel  ;  see  also  Filipkiewicz, 
Briining,  Perrand  and  Lemaire,  Kaurin,  Bartholdy  and  Termin. 
Abrami  and  Burnett,  Roily,  Korczewski,  Korczynski  and  Bylina, 
Briickner,  Poten  and  Griemert).  If  the  cutaneous  tests  prove 
negative  it  must  be  repeated  after  eight  days,  or  the  streak  test 
must  be  tried. 

The  ointment,  conjunctival  and  streak  tests  are  equal  in  value 
to  V.  Pirquet's  test,  and  have  apparently  the  advantage  that  they 
do  not  indicate  inactive  foci  to  the  extent  of  the  latter;  we  must, 
however,  object  to  the  conjunctival  test,  since  a  number  of  severe 
injuries  have  been  observed  from  it  (see  Heinemann,  Emmerich, 
Bullinger,  Wideroe  [186  cases'],  Weil,  Chlumskv  and  others). 

The    \ery    interesting    phenomenon    has    occurred    in    these 


I)(A(;n()si.s  26-5 

allergic  lesls  llial  siil).sc(|iiciil  suhciilaiKMMis  injcclions  lead  l<)  a 
pronounced  reinn.'imninlion  of  liic  old  silcsof  injccijrtn  in  the  skin 
and  coiijiincl iv.'i  even  wlicn  iIm'  .s\  inpif iins  li.i\<-  all  disappeared, 
and  (lie  Icsl  look-  place  weeks  and  e\cn  inonllis  before  (in  one  case 
of  C'aloir  li\c  nionllis).  This  revival  occurs  also  in  cases  in  wliich 
llie  resiill  (if  llie  former  Iikk  iilai  ii m  was  (loiil )i  I  n I,  even  negative. 

As  il  also  occurs  in  cases  in  which  tubf-rciilin  injection  induces 
no  fever,  it  is  clear  I  hat  the  hypersensitive  focus  which  has  been 
crealed  for  a  lnn<^  lime  is  localK  ciicumscribed  (Citron,  ('olin, 
Baginsky,  Le\y,  (."aan,  Lenliarl/,  I'eer,  BinL;,  ("ollin,  (ioebel. 
Blum  and  Schlippe). 

Subcutaneous  Tuberculin  Test. 

In  cloublful  cases  one  can  alwavs  reiurn  lo  llie  subcutaneous 
tuloerculin  lesl,  but  this  cannot  be  used  in  patienis  suffering  frrjm 
fever,  and  in  weakly  patients  it  is  hardly  applicable  on  account  of 
the  fever  produced  by  it. 

One  must  first  assure  oneself  of  the  normal  temperature  by 
recording  it  everv  two  hours  for  three  days;  then  late  in  the 
e\'ening  a  first  injection  of  J  to  i  mg.  is  gixen.  Reaction  may  be 
expected  after  eight  to  sixteen  hours,  and  shows  itself  by  fever, 
tliat  is,  an  increase  of  at  least  o'5°,  prostration,  and  perhaps  a  focal 
reaction.  The  two  hourlv  record  must  of  course  be  continued 
during  the  time  of  observation.  If  no  reaction  follow,  one 
injection  of  3  mg.  is  given  on  the  fourth  day,  should  the  result  be 
still  negative,  5  to  6  mg.  is  given  on  the  seventh  or  eighth  day. 
If  reaction  is  still  wanting  in  all  probability  tuberculosis  is  not 
present.  Children  under  10  are  given  o'l — o"3 — 1"5  mg. ;  under 
5  years  o'l— 0*3 — o'6 — r^  mg. ;  for  delicate  persons  the  initial 
dose  is  o"i  mg.,  and  for  delicate  children  o'os  mg. 

For  prognosis  in  general,  for  reasons  alreadv  given,  a  severe 
cutaneous  reaction  is  considered  of  more  favourable  import  than 
a  weaker  and  slower  reaction  (Levy  and  others).  In  pronounced 
tuberculosis  negative  reaction  is  considered  an  unfavourable  sign 
(Wetzel  and  Wilson  and  others),  and  often  signifies  an  aggrava- 
tion of  the  disease,  if  some  time  before  reaction  were  positive 
(Bartholdi  and  Ternim.  Korczewsky,  Korczvnski  and  Bvlina,  and 
Comby) . 

Lapschin,  Fabian  and  Knopf  attribute  a  certain  prognostic 
value  to  reaction,  but  in  other  quarters  little  value  is  attached  to 
it,  and  at  times  it  has  been  contended  that  the  quantity  of  anti- 
bodies is  in  no  proportion  to  the  severity  of  the  disease  (Calmette), 
and  that  severe  sutTerers — for  example,  thirteen  out  of  nineteen 


264  SCROFULOSIS 

posl-niortoii  cases — had  reacted  pi'siiixely  to  one  inoculaiion  with 
I  per  cent.  luInTculin  (Aisierniann,  Noggerath  ;  see  also  Burck- 
hardl,  Roepke,  Hans,  Baldwin,  Ziegler  [600  patients]  ). 

In  general  \ve  cannot  attach  much  value  to  the  prognostic 
reliability,  and  Wolff-Eisner's  supposition  that  the  prognostic 
value  of  the  conjunctival  reaction  is  higher  than  the  diagnostic 
value  appears  not  to  be  juslitied. 

Allergie  Reaction  in  the  Scrofulous. — Reaction  apjx'ars 
after  the  most  various  methods,  especially  regularly  and  severely 
marked  in  children,  often  with  the  formation  of  crusts  and  scabs, 
more  parlicularh-  in  scrofulosis,  and  bone  and  joint  tuberculosis 
(Citron,  I^>er,  Cioebel).  Thus  among  sexenieen  children  with 
bone  tuberculosis  sixteen  showed  a  positive  reaction,  and  in  ilfty- 
four  sulTering  from  bone  and  joint  tuberculosis,  fiflx'-thrce  showed 
a  positi\e  reaction,  vet  Chlumsky  (who  in\esligated  150  cases)  in 
twentv-four  assured  cases  of  surgical  tul^erculosis  only  had  positive 
results  fourteen  times  (see  also  Briining,  Monti,  A\'ilms).  The 
more  violent  the  reaction  the  more  it  points  to  the  scrofulous 
character  of  the  tuberculosis.  Tiiese  decided  skin  reactions  have 
led  to  the  lielief  in  a  specific  hvpersensibilitv  of  the  skin  in  tuber- 
culosis of  the  skin  and  scrofulosis  (Moro,  Oppenheim,  Bandler 
and  Kreibich).  In  scrofulosis  papules  often  appear  10  to  20  mm. 
in  diameter,  which  become  gradually  pale,  and  mav  be  long  recog- 
nized as  pigmented  spots  (Kngel  and  Bauer).  The  production  of 
nodule's  resembling  lichen  has  been  mentioned  elsewhere 
CReuschel,  Zieler,  Oppenheim).  The  reaction  mav  take  the 
exact  appearance  of  tuljerculides.  Now  and  then,  after  seven, 
eight,  or  inore  davs,  when  one  has  begun  to  think  the  inoculation 
w^ould  have  a  negative  result,  plilyctena?  of  the  cornea,  or  a  sort 
of  folliculitis  (small,  round,  raised  papules)  appear,  of  bright-red 
colour,  with  a  central  depression  (Engel  and  Bauer,  Pfaundler, 
Moro,  Doganoff). 

It  is  remarkable  that  v.  Pirquet  demonstrated  in  a  child, 
which  reacted  positively  but  which  on  autopsy  Avas  proved  to  be 
tuberculous,  a  decided  status  lymphatictis,  which  led  him  to 
suppose  some  connection  between  the  status  lymphaticus  and 
tuberculosis.  But  in  a  similar  case  of  Engel  and  Bauer  the 
status  lymphaticus  was  wanting. 

The  observation  of  Wolff-Eisner  and  Brandenstein  that  the 
erethistic  form  of  scrofulosis  shows  a  positive,  and  the  torpid  form 
a  negative,  reaction  has  not  been  confirmed. 

The  reaction  symptoms  which  are  more  severe  in  scrofulosis 
may,  in  the  eye,  readily  have  grave  import.  Mongour  and 
Brandeis  observed  suppurative  conjunctixitis  after  the  conjunctival 


I)F,\(;nosfs  265 

Icsl,  Levy  twice  observed  suppurative  inllamniati(jn  of  the  eye, 
and  Lapardt  severe  corneal  infillration  in  lupus  of  the  face. 
Siegert  notes  in  his  lupus  patients  the  relatively  slow  reacti(jn  as 
compared  with  those  suffering  from  internal  tuberculosis.  Now 
and  again  phlycten^c  appear,  and  more  severe  affections  as  well 
as  aggravation  of  ophthalmic  processes  '  already  existing  in 
scrofulous  patients,  even  with  i  percent,  old  tuberculin. 

Wc  therefore  consider  the  ronjunclival  test— which  we  never 
emplo\-  on  .-icconni  of  ihe  danger  connected  with  it  —  relatively 
contra-indicaled,  and  we  employ  either  v.  Pirriuet's,  the  (tintmeni 
or  streak  reaction,  which  at  times  gives  us  very  valuable  indica- 
tions, especial  1\  in  conneclion  with  other  means  of  diagnosis. 
If  the  reaction  be  negative,  or  disappear  rapidly,  so  that  it  cannot 
be  considered  entirely  conclusive,  the  test  is  to  be  repeated,  as 
alreadv  mentioned,  after  eight  days  in  the  same  form,  or  as  a 
streak  test.  In  fresh  or  recently  healed  eye  affections  even  the 
percutaneous  test  is  only  to  be  employed  with  great  reserve  (see 
Brijckner). 

I  have  recourse  to  subcutaneous  injections  for  diagnostic 
purposes  onlv  in  exceptional  cases,  as  they  have  a  complete 
equivalent  in  percutaneous  tests.  Although  small  doses  are  almost 
innocuous,  in  the  larger  doses  \vhich  are  necessary  U)  produce 
reaction,  an  injury,  though  rare,  is  not  entirely  excluded,  and  such 
injury  generally  escapes  observation,  as  it  only  manifests  itself 
some  months  later  owing  to  the  slow  growth  of  the  tubercle 
bacillus.  On  account  of  the  frequent  close  symptomatic  con- 
nection between  tuberculosis  or  scrofulosis  and  svphilis,  it  would 
be  advisable  in  a  case  of  a  negative  result  of  the  tuberculin  test  to 
test  for  the  other  affection  by  Wassermann's  reaction.  Thus  Hertz 
and  Thomsen  in  228  scrofulous  children  had  192  positive  v. 
Pirquet  reactions ;  of  the  remaining  thirty-six,  eight  showed 
Wassermann's  reaction  (see  also  Marshall  and  others). 

Differentiation  of  the  Hun\an  and  Bovine  Bacillus. 

The  extremely  important  decision  as  to  whether  in  certain 
cases  we  are  dealing  with  human  or  bovine  tubercle  bacilli  is  for 
the  present  surrounded  with  considerable  difficulties,  and  prac- 
tically cannot  be  carried  out. 

Just  as  the  fact  derived  from  the  historv  of  the  case,  that  about 
the  time  of  the  infection  raw  milk  and  milk  products  from  tuber- 
culous cows  had  been  consumed,  can,  when  dealing  with  tuber- 
culosis of  the  digestive  organs  and  neck  glands,  give  a  certain 
clue,  so  the  demonstration  of  tuberculous  persons  living  in  close 


266  SCROKULOSIS 

proximily   lo   the   paiieni   t>r   rliiki    may  give   a   certain    hint,   but 
beyond  this  no  great  value  can  be  placed  on  the  history. 

Macroscopicallv  no  difference  can  be  demonstrated  in  the 
organs  examined.  Microscopically  also  the  differences  arc  not 
decisive. 

Benda  remarked  in  most  cases  of  bovine  tul)erculosis  the  lack 
of  giant  cells  and  a  greater  cjuanlity  of  the  tubercle  Ixacilli,  the 
confirmation  of  which  in  the  jnis  of  the  glaml  (in  a  smear  pre- 
paration) is  easier  than   in  luiman  tuberculosis. 

Besides  which,  the  human  tvpe  exhibits  morpliDlogically  a 
longer  and  more  slender  shape,  the  same  ihickness  ai  hoih  ends, 
and  absorbs  staining  matter  regularly;  the  bovine  t}  pe  has  a 
shorter  shape  like  o\aI  cocci,  the  larger  ones  are  more  extended 
and  man\-  are  club-shaped  (similar  to  the  bacilli  (^f  diphtheria), 
the  (me  end  better  coloured,  and  thickened  like  a  button.  These 
differences  can  onl\-  be  clearlv  distinguished  in  fresh  cultures, 
prepared  in  exactly  the  same  manner  (Kossel). 

A  decision  as  to  the  etiological  connection  of  any  affection 
with  human  or  bovine  tuberculosis  can  only  be  arrived  at  by 
bacteriological  tests  and  experiments  on  animals. 

Kossel,  Weber,  and  their  collaborators,  Heuss,  Oehlecker, 
Taute  and  others  have,  with  the  co-operation  of  Robert  Koch, 
worked  out  an  exact  method  of  differentiation  which,  it  is  true,  is 
troublesome  in  practice  and  exacting  in  its  conditions,  but  is 
adapted  to  avoid  all  the  numerous  rocks  of  error  in  experiments 
on  whic^h  the  reliabilil\'  of  the  greater  part  of  such  experiments 
suffer  shipwreck.  The  proceeding  is  based  on  cultural  signs, 
on  subcutaneous  inoculation  experiments  on  rabbits,  and  in 
doubtful  cases  on  cattle.  The  sterling  works  of  Hans  Burckliardt 
contain  very  exact  accounts  of  the  differentiation  in  culture,  and 
in  experiments  on  animals,  as  well  as  valuable  hints  as  to  how- 
such  experiments  may  be  exactlv  and  economicallv  carried  out. 

These  experiments  are  easily  subject  to  errors.  Koch  attri- 
butes the  contradictory  results  of  other  investigators,  and  also 
those  in  his  own  statements,  to  not  paying  attention  to  sources 
of  error,  and  has  drawn  up  a  series  of  maxims  in  order  to  avoid 
them. 

To  obtain  a  result  free  from  all  objection,  the  animals  chosen 
for  experiment  must  be  without  idiopathic  tuberculosis.  To  avoid 
mistakes,  a  large  number  of  animals  must  be  used.  The  danger 
of  idiopathic  tuberculosis  is  especially  great  in  cattle,  for  even 
tuberculin  only  shows  a  tuberculous  infection  after  some  time. 
A  small  number  of  experiments  has  only  a  conditional  value, 
and    solitary   exceptions    in    a    large    number    are    generally    the 


DIACNOSIS 


>67 


consequenco  of  f.-iiillv  (■Npcrimcnls.  ['"iirilicr,  ilic  animals  inusi 
be  slriclly  gii.'iidcd  lioni   iininiini  ion.-il   iiilc(ii(iii   by  separation. 

lun-  conclusive  comj^arisons  I  lie  ino(iilaiion  sliouUJ  not  be 
made  will)  p.-irliclrs  of  lissiic,  bin  wiili  a  (arcfnlly  weiglif^d  mass 
of  culture,  and  nol  wiili  loo  l.-irgc  doses;  also  not  an  intra- 
peritoneal, nor  an  intravenous,  but  a  snb( nianeous  injertion 
should  be  ni.-idc,  as  olhcrwisf  non-vinilcni ,  cx'n  dead,  iKicilli  may 
induce  siniil.ir  cliaiii^cs  by  toxins,  or  llic  (■{]'(•(  \  of  foreign  bodies 
{e.g.,  tubercle  bacilli  no!  snrri(i<nily  finely  .lisintegrated).  fSee 
Kossel's  experiments  willi  'I'iniolliy  bacillus.) 

The  material  nnisl  lirsl  be  injected  into  giiinea-i)igs,  to  avoid 
any  failure  with  direct  culture,  especially  as  such  passage  through 
guinea-pigs  does  not  influence  the'  character  of  the  culture  in  any 
perceptible  degree;  from  this  a  pure  (ullure  is  to  be  made,  and 
a  culture  v^hich  is  not  too  old,  either  in  the  first  or  second  genera- 
tion, first  for  bouillon  culture,  then  for  inoculation  into  rabbits. 
The  animals  must  be  allowed  to  live  long  enough  to  enable  one 
to  distinguish  between  progressive  and  retrogressive  processes. 
When  the  result  is  doubtful  further  tests  must  be  made  on  a 
number  of  cattle. 

We  must  take  into  account  the  possibility  of  mixed  infection 
of  bovine  and  human  types  with  which,  in  experiments  on  animals, 
the  bovine  bacilli  can  get  the  upper  hand  and  lead  to  errors  (see 
the  cases  of  Kossel,  Weber,  Heuss,  and  others). 

In  sputum  tests  the  possibility  of  particles  of  food  which 
contain  butter  or  milk  must  be  carefully  excluded.  Koch  points 
especiallv  to  such  faults  in  experiments  on  the  part  of  the  English 
Commission. 

These  maxims,  the  justice  of  which  must  be  acknowledged, 
are  to  be  the  measure  by  which  their  value  and  convincing  power 
in  such  experiments  are  to  be  judged. 

The  course  of  investigation  which  is  of  great  importance  for 
scrofulosis  is,  accordinp-  to  these  maxims,  to  be  arransred  as 
follows  : — ■ 

Passage  through  Guinea-pigs. — The  material  which  is  to  be 
tested  for  its  origin  and  type  is  to  be  triturated  into  the  smallest 
possible  particles,  and  if  an  emulsion  can  be  made,  injected  subcu- 
taneously,  or  into  a  fold  of  the  skin  in  the  right  abdominal  region 
of  two  or  four  guinea-pigs.  To  guard  against  idiopathic  tuber- 
culosis the  animals  must  be  kept  separated  a  long  time  before- 
hand and  secureci  against  possibility  of  infection.  Guinea-pigs 
are  used  for  the  passage  of  the  material,  as  thev  are  easilv  sus- 
ceptible to  both  types.  They  die  somewhat  more  quickly  from 
bovine  infection,   but  sometimes  with   less  extensive  changes  in 


268  SCROFILOSIS 

the  organs  than  wlu'n  inoculaied  wiili  human  i>pt-\  appari'nily  on 
account  of  increased  itixic  effect  (Oehlecker). 

After  eight  to  fourteen  clays  the  enlarged  glands  lying  nearest 
to  the  site  of  inoculation  can  be  distinctly  felt;  after  about  four 
weeks  the  animal  is  killed,  and  the  most  suitable  j^orlion  of  the 
spleen  or  other  tuberculous  organ  is  emj^loyed  for  making  cultures. 

To  obtain  a  speedier  result  Bloch's  crushing  method,  in  con- 
junction with  aniiformin,  mav  be  employed  (see  p.  250).  But  as 
a  safeguard  a  second  animal,  in  which  the  glands  ha\(^  not  been 
crushed,  should  be  kept  in  reserve,  bui  only  used  for  cultures 
after  four  weeks. 

Serum  Culture. — Sertmi  without  (or  according  to  liurckhardt 
with  3  P''r  ccni.)  ghcerine  has  pro\"ed  the  best  ciiliure  mediimi 
for  ihis  purpose. 

in  siaugiuering,  the  blood  of  the  animal  is  caught  in  a  sterile 
recei\-er  and  k-epi  in  a  cool  place,  the  sertmi  which  has  separated 
is  centrifugalized  after  three  days,  placed  in  lubes,  and  then 
closed  with  cotton-wool,  subjected  to  fractional  sterilization  on 
the  three  following  days,  every  three  hours,  at  58°,  then  placed 
in  the  ice-chest.  Before  use  the  tubes  must  be  placed  to  set  in 
paraffin  at  70°  in  a  moist  atmosphere,  obtained  b\'  saucers  of 
water. 

The  tuberculous  particles  of  tissue  of  the  guinea-pig  to  be 
inoculated  are  well  crushed  with  the  forceps  and  rubbed  into  the 
serum  with  a  platinum  spatula  in  six  or  twelve  tubes,  the  tubes 
closed  with  cotton-wool  pushed  slightly  into  the  tube  and  then 
singed  at  the  top,  to  guard  against  evaporation  and  the  intru- 
sion of  bacteria,  at  first  boiling  hot,  and  then  warm  paraffin  is 
poured  on  it  (or  the  cotton-wool  cork  is  soaked  in  \-er\-  hot  paraffin) 
and  the  tubes  are  placed  in  the  incubator. 

As  a  precautionary  measure  it  is  ad\-isable  to  inoculate  another 
guinea-pig  with  particles  of  the  organ  to  carrv  on  tlie  stock. 

The  formation  of  a  so-called  salt  film  often  disturbs  and 
hinders  growth  in  the  serum  culture  medium.  With  normal 
development  the  appearance  of  the  serum  tube  culture  will,  after 
a  short  time,  allow  of  a  conclusion,  even  if  not  a  binding  one,  as 
to  which  of  the  types  we  have  before  us. 

The  human  type  forms  a  drier,  more  brittle  la\er,  pushing 
itself  up  the  side  of  the  tube. 

The  bovine  type  is  more  difficull  to  c-ul(i\ate,  rises  up  the 
side  more  slowly  and  more  scantih",  and  is  inclined  to  become 
merged  into  one. 

Buckhardt  succeeded  in  some  cases  in  preserving  bovine 
strains  on   glycerine  agar,   and   he  prefers  this  culture  medium, 


I))A(;no.sis  260 

wliicJi,  by  iIh'  l)y,  ii''is  Iohl;-  been  used  for  cxpfriiiifnls  in  flillerf-n- 
li.'ition  in  llic  place  ol   llic  (roiibicsonic  scrinn  (\\\\\\y<-. 

'I"li<>  livinsniission  of  \\\c  <  iilinrc  lo  ih*^  ^^1  yccrinc  bonillon  may 
take  place  in  from  tinee  lo  six  weeks,  l)Ul,  ii  llie  gnnvtli  be  loo 
scanty  liie  culfure  is  a^^-iin  [o  be  transpianl(;d  on  s(;rijm,  when 
enou'Tli  ni.'ilcrial  lor  fiiiilicr  inocnlalion  will  be  obtained  in  two 
or  three  weeks. 

Glycerine  Bouillon  Culture. — h^)r  bouillon  cnlinre  we  employ 
a  sli<^hllv  acid  2  per  cvni.  glycerine  bouillon,  which  is  lilled  into 
llasks  which  have  before  been  tested  as  to  their  suitability  for 
tlie  culture  of  tubercle,  each  containing  -^o  r.c. 

To  obtain  reliable  results  in  llie  comparison  of  cultures  it 
is  advisable,  according  to  Oehlecker,  Burckhardt,  and  others,  to 
prepare  at  one  time  a  large  quantity  of  glycerine  bouillon,  so  as  U) 
ensure  a  uniform  culture  medium  and  thus  avoid  slight  differences 
in  growth,  due  to  variation  in  the  culture  medium. 

The  serum  cultures  are  now  carefully  taken  off  with  a  platinum 
spatula  and  inoculated  into  about  a  dozen  small  flasks  Hlled  with 
glycerine  bouillon.  It  requires  some  practice  to  get  the  layers 
of  culture  from  tlie  serum  medium  into  the  flasks  without  letting 
them  sink  to  the  bottom.  The  more  thinly  the  cohering  film  of 
culture  is  laid  on,  the  more  characteristic  the  growth  becomes. 

The  further  development  of  the  culture  goes  on  in  the 
incubator  relatively  quickly,  and  soon  distinct  differences  are 
perceptible. 

In  the  human  type  the  film  spreads  tolerably  quickly  and  in 
from  three  to  four  weeks  spreads  itself  out  in  a  layer,  intersected 
by  folds,  covering  the  whole  of  the  surface  of  the  bouillon  and 
rising  up  the  side  of  the  vessel.  It  becomes  gradually  thicker, 
at  first  forming  fine,  crinkly  folds,  but  the  surface  is  soon  covered 
with  light-yellow,  puffy  masses  of  folds,  a  condition  wJiich  has 
been  known  for  decades.  At  the  fifth  week  it  becomes  darker 
and  a  dirty  yellow,  single  fragments  are  loosened  and  fall  to  the 
bottom.  If  the  particles  of  culture  have  been  laid  on  more  thickly 
the  growth  is  slower  and  looks  more  like  felt. 

The  bovine  type  is  distinguished  by  its  slow  growth.  The 
delicate  film,  often  thin  as  tissue  paper,  show^s  no  puffed-up  folds, 
but  little  wart\  excrescences,  which  develop  more  on  the  under 
surface  of  the  film",  which  often  appears  grained  like  "  finely  and 
closely  punched  leather  "  (Burckhardt). 

The  cultures  differ  most  distinctly  after  three  or  four  weeks 
and  permit  of  a  certain  diagnosis  of  their  origin,  which  may  then 
be  confirmed  by  experiments  on  animals. 

Bonome  has  proposed  a  method  of  distinguishing  the  two 


270  SCROFLLOSIS 

types  by  precipitation;  Speiigler  also  rcHdniniciHled  a  similar 
method.  Theoljald  Smith  einphasizes  the  tiualiiy  possessed  by 
the  bovine  Ivpe  oi  redueing  the  acidii\  in  a  ^^^  lo  3  per  cenl. 
glycerine  bouillon  with  a  degree  of  acidity  ot  2  pw  cenl.  normal 
acid  (with  phenolphthalein  as  indicator)  to  weak  alkaline  reaction. 
These  methods  have  been  confirmed  only  in  jxirt,  or  at  least  not 
to  their  full  extent  (Mohler,  Washburn,  P'ibiger  and  Jensen, 
Beitzke,  G.  Schroder). 

According  to  Arpad,  based  on  Wolbach  and  Ernst,  the 
human  type  on  glycerine  potato  forms  a  yellowish-red  dye;  the 
bovine  tubercle  bacilli  remain  white;  Beitzke,  Dammann  and 
Miissemeier,  Lvdia  Rabinowitsch,  Weber,  as  well  as  Burckhardt, 
tind  this  phenomenon  constant,  and  therefore  not  adapted  to 
difTerentiation.  The  exuberant  growth  of  luiman  bacilli  on  egg- 
culture  medium,  noted  bv  Dorset,  has  been  contirmed  by  Wolbach 
and  Ernst. 

Testing  on  Animals. — l-'or  this  purpose  tin-  human  bacilli  are 
taken  after  twenty  to  thirty  days,  the  bovine  bacilli,  on  account 
of  their  slower  growth,  about  fourteen  days  later,  with  a  sterile 
platinum  loop,  then  placed  on  good  blotting-paper,  and  when  the 
bouillon  has  been  soaked  up  (after  live  to  ten  minutes)  placed  on 
a  watch-glass  of  known  weight  and  the  contents  weighed. 

Then,  according  to  weight,  they  must  be  made  up  with 
o'8  per  cent,  sterile  solution  of  common  salt,  so  that  each  c.c.=^ 
I  eg.  of  culture  mass  (for  example,  in  an  amount  of  culture 
weighing  o"85,  8'5  salt  solution  is  necessary).  Hie  culture  mass 
must  first  be  cautiouslv  (as  sometimes  in  this  nianipulation  rigors' 
are  induced  [Oehlecker])  and  thoroughly  rubbed  down  in  a  steri- 
lized porcelain  mortar  and  the  salt  solution  added  drop  by  drop; 
the  mixture  is  best  inoculated  at  once,  as  the  bacilli  settle  ^•er^■ 
quickly. 

For  testing  in  aninials  a  rabbit,  of  about  the  weight  of 
2,000  grm.,  is  used  ;  this  does  not  entirely  replace  the  ox,  which  is 
much  dearer,  but  on  account  of  its  characteristic  of  not  exhibiting 
any  tuberculosis,  or  only  slight  changes,  when  injected  subcu- 
taneously  with  not  too  great  a  quantity  of  human  bacilli  (when  the 
same  quantity  of  bovine  bacilli  subcutaneouslv  introduced  would 
cause  decided  tuberculosis  and  would  k'ill  the  animal),  allows 
us,  as  a  rule,  to  draw  a  sufficiently  reliable  and  clear  conclusion 
as  to  the  origin  and  type  of  the  bacillus.     Besides  the  infinitely 

'  Leschke  also  notices  the  poisoning  from  the  smell  which  sometimes 
occurs  whilst  working  with  solutions  of  tubercle  bacilli,  and  which  he  has 
himself  experienced,  rigors,  increase  of  temperature  of  short  duration, 
pains  in  the  limbs,  stupor,  confusion  of  ideas,  which  passed  off  after  about 
three  davs. 


DIACiNOSIS  J/l 

sm.'illcr  cosl  ol  (lie  i'<'il)l)il  .iml  lis  Ixin^  mkjic  c-isjIn  k'-pl,  il  lias 
also  llic  ,'i(l\  .'1  nlai.;''  "I  scldmn  hiin.M  k  in  (p.-ii  Im  a  11  \  .'illcclr-d  willi 
luberculosis,  which  in  caiilc  olicn  'j^\\>-s  lisf  in  errors. 

'riic  clcpitsil  (il  i)a(  illi  |)r<-|);iic(l  in  ihc  inannf-r  iiicni  lonccJ 
([  c.c.  o'oi  ^I'ln.  ciiliiiic  mass)  is,  atici'  i"<Mno\al  nl  ilic  hair,  dis- 
infection, and  caref'iil  avoidance  of  small  veins,  S(;  as  nol  to  ^el  a 
direct  blood  infection,  suhciilaneniish  inie(ied  into  the  abdomen, 
pushing  the  needle  cauiioiisl)-  forward  allei-  ihe  punelure  wiliioul 
stretching  the  skiri.  If  fewer  than  foiii-  animals  are  employed 
llie  result  often  ajipears  less  certain  and  uner|uivo(al,  as  one  may 
meanwhile  die,  and  another,  on  accounl  of  indixidiial  tendency, 
may  react  more  or  less  decidedly. 

According  lo  Weber  we  must  guai'd  againsi  ini  ramns(  ular 
infection,  which  might  induce  great  liiheic  iiloiis  changes  in  the 
raJibils  even  with  the  human  type. 

Burckhardt  specially  recommends  subepidermal  injection,  in 
which  there  is  less  danger  of  piercing  a  \ein  (by  which  infection 
through  the  blood  oc(airs),  and  in  which  the  difference  between 
bovine  and  human  infection  is  more  sharply  detmed,  the  skin  of 
the  abdomen  is  fixed  during  the  injection  and  pierced  as  super- 
ficially as  possible,  as  if  the  needle  were  to  remain  in  the  epidermis. 

For  my  part,  I  see  one  disadvantage  in  this,  viz.,  that  the 
abscesses,  which  are  formed  more  readily,  burst,  and  by  the  dis- 
persal of  infectious  material  further  both  simultaneously  and  later, 
spontaneous  and  double  infections. 

The  result  of  the  inoculation  exhibits  a  cardinal  difference. 
If  the  bacilli  are  of  human  type,  at  the  most,  a  transitory  swelling 
of  the  nearest  gland  appears  in  the  rabbit,  which  involutes  after  a 
time,  but  frequently  the  gland  remains  normal  and  exhibits  no 
tuberculous  changes  if  the  animal  be  killed  after  four  months;  the 
inoculation  of  the  gland  into  guinea-pigs  is  often  unsuccessful 
(Oehlecker).  Only  at  the  site  of  injection  does  a  callosity  appear, 
or  more  frequentlv  an  inoculation  abscess,  varving  in  size  from 
a  hazel-nut  to  a  hen's  egg,  with  caseous  suppurative  contents. 
Burckhardt  only  found  caseated  glands  in  two  cases.  Thus  the 
evidence  of  advancing  tuberculosis  is  wanting. 

Now  and  again  small  foci  are  found  in  the  lungs,  general'v 
only  fibroid  tubercles,  contracting  or  healing  processes ;  in  the 
kidneys  it  is  very  rare  to  find  any  small  suspicious  foci. 

Burckhardt  considers  that  Oehlecker's  statement,  that  rabbits 
never  die  from  cutaneous  inoculation  of  human  bacilli,  is  going 
too  far,  and  considers  it  much  more  probable  that  if  one  allowed 
the  rabbits  to  live  more  than  four  months  the  greater  part  of  them 
would  die  later,  thus  the  end  is  only  delaved. 

Tromsdorff  informs  us  of  parallel  experiments  on  white  mice, 


272  SCROFULOSIS 

in  which  these  animals,  having  been  inoculatetl  wilh  bovine  bacilU 
in  the  veins  of  the  tail,  died  tour  weeks  later  from  general  tuber- 
culosis, whilst  when  inoculated  with  the  human  type  two  to  three 
and  a  half  months  after  not  a  single  one  luul  died  of  idiopathic 
tuberculosis.  JMice  and  rats,  according  to  Beck,  exhibit  differences 
in  such  inoculations,  even  if  not  always  distinct.  The  regional 
glands  are  apparently  more  severely  imi)licated  in  ral)l)iis  only 
when  human  bacilli  are  inoculated  into  the  anterit)r  chamber  of 
the  eye,  as  the  experiments  of  Cohnlieim,  Koch,  G.  Cornet,  Take- 
wossianz,  and  others  proved. 

Should  the  material  for  inoculation  be  of  the  bovine  type,  in 
all  animals  a  distinct  enlargement  of  the  regional  glands  is 
exhibited  after  three  or  four  weeks,  from  which  a  thick  cord  of 
inflamed  lymph  vessels  extends  to  the  site  of  inoculation;  if 
the  animals  die  spontaneously  (as  a  rule  after  forty  to  a  hundred 
days),  or  if  they  be  killed  after  four  months,  they  exhibit  severe 
tuberculosis;  caseated  glands  up  to  the  size  of  a  walnut,  large 
foci,  espL-ciallv  in  lungs  and-  kidneys,  submiliary  nodules  in  the 
spleen  and  liver. 

Of  diseases  of  rabbits  which  often  interfere  with  the  experi- 
ment, septicaemia  is  to  be  especially  noted,  the  causative  agents 
of  which  are  small  ovoid  bacilli,  staining  at  the  extremities.  It 
shows  itself  by  loss  of  appetite,  quickened  breathing,  and  wet 
nose;  the  pathological  changes  are  fibrinous  deposits  in  the  lungs, 
fibrinous  and  suppurati^•e  pleurisy,  and  pericarditis,  all  of  which 
might  erroneously  be  taken  as  of  tuberculous  origin. 

V^ery  frequently  the  cause  of  death  is  found  to  be  coccidiosis 
of  the  liver,  irregular  yellow  liver  foci,  which  in  a  smear  prepara- 
tion show  coccidia  and  which  are  not  really  looked  upon  as  tuber- 
culous changes,  as  even  1  have  known  to  be  done  by  a  tolerably 
well-known  pathologist.  In  coccidiosis  of  the  intestine  with 
enteritis  (also  a  frequent  cause  of  death),  cysticerci  are  found  in 
the  reticulum,  leaving  in  their  train  abscesses  with  caseous  sup- 
purative contents,  forming  another  source  of  error  when  mistaken 
for  tuberculous  reticulum  nodules. 

They  also  occur  in  the  Ccucum,  at  the  peripheral  end  of  which 
Oehlecker  has  found  small  yellow  foci,  the  size  of  a  pin's  head, 
lying  in  lymph  nodules,  which  even  histologically  might  resemble 
an  incipient  tuberculosis  (epithelioid  cells,  but  no  giant  cells), 
which,  however,  apparently  have  nothing  to  do  wilh  lubcrcuiosis, 
as  is  proved  by  inoculating  them. 

To  shorten  the  proceeding,  which  demands  time  and  is  costly, 
we  may  resort  to  intravenous  inoculations,  which  in  rabbits  lead 
to  useful,  if  not  always  unequivocal,   results;  but   instead  of  fh( 


DIAGNOSIS  273 

dose  formcrlv  rc(  ommcndi-d  by  Kosscl  and  W'-Ij'T,  o(  i  111^'., 
wliicli  by  iIm-  ctl'''  I  nl  idxins  ;ind  tnrcign  bodies  mi^lii  h-ad  to 
death,  only  a  dose  ol  ,,',„  mg.  is  lo  be  used,  as  eslablislied  by 
Oeldecker,  or  else  \\u-  differences  l)el.wecn  liuiii.'ui  and  bovinf; 
injcclinns  an-  sonid  im^s  cllacfMl. 

.Should  the  rabbiL  not  gi\<-  iiiic(|uivo(al  results  the  experiment 
must  be  repeated  on  a  larger  number,  or  (which  can  rarely  be  done 
in  practice)  on  voung  cattle  which  have  been  proved  by  tuber- 
culin to  be  heaUhy  (for  precautionary  measures,  see  pp.  32  and 
267),  which  afford  the  surest  means  of  differentiation  ;  5  c.c.  in 
50  mg.  of  culture  mass  and  physioU)gical  salt  solution  is  subcu- 
laneotisly  injected  in  the  neighbourhood  of  the  prescapular  gland. 
An  inlravenous  injCciion  is  avoided,  as  human  cultures  ma\'  some- 
times prove  actively  virulent  in  intraven(jus  injections  in  cattle 
in  consequence  of  high  toxic  properties  (see  Koch  and  Oehlecker) ; 
avian  luberc-ulous  strains  intravenously  injected  in  cattle  often 
lead  to  death  by  toxins  for  the  same  reason  (Weber). 

In  infection  with  the  human  type,  besides  infiltration  and 
abscesses  at  the  site  of  injection,  swelling  oi  the  prescapular  gland 
in  connection  with  it  occurs,  sometimes  of  considerable  size;  but 
these  symptoms  involute  and  the  fever,  which  may  have  inter- 
vened, disappears  after  a  few  weeks.  If  the  animals  be  slaughtered 
after  four  to  six  months,  wath  the  exception  of  tumours  of  the  con- 
nective tissue,  up  to  the  size  of  a  goose's  egg,  at  the  site  of 
injection,  no  other  changes  are  found;  or  at  the  site  of  injec- 
tion, small  caseous  suppurative  or  calcified  foci  are  met  with,  or 
caseous  chalky  foci  in  the  prescapular  glands,  or  even  in  the 
nearest  -glands,  which  are  in  a  clear  state  of  involution,  as  we 
have  described  on  p.  117,  but  other  organs  are  free  from  tuber- 
culous changes.  We  have  to  do,  therefore,  with  a  strictlv 
localized,  non-advancing  process,  with  retrogressive  meta- 
morphoses. 

With  infection  by  bovine  type  in  cattle,  extensive  swellings 
and  abscesses  are  formed  at  the  site  of  injection,  there  is  great 
enlargement  of  the  prescapular  gland  and  neighbouring  glands, 
up  to  the  size  of  a  man's  head;  and  high  fever,  which  remains 
constant  for  a  long  period,  even  till  death,  which  generally  occurs 
in  from  forty  to  seventy  days.  If  the  animal  does  not  die  spon- 
taneously, but  is  killed  after  four  to  seven  months,  it  exhibits  the 
evidences  of  general  disseminated  tuberculosis  with  tuberculous 
nodules  the  size  of  a  pea  in  spleen,  liver,  lungs  and  kidnevs. 

It  would  be  of  great  diagnostic  and  prognostic  value  to  be  able 
to  confirm  rapidly  to  which  type  of  bacillus  a  case  before  us  belongs, 
for  the  troublesome  differential  diagnostic  method  bv  which  we  are 

18 


274  SCROFULOSIS 

at  present  bound  is  inapplicable  in  practice;  therefore,  at  the  same 
time  Tedeschi  and  Delre  tried  to  bring  out  such  a  differentiation  by 
means  of  cutaneous  inoculation,  employinj;-  siniuhancously  lul^er- 
culin  of  human  and  bovine  type,  ok!  uil)('rciilin,  and  the  even  more 
effective  htmian  and  bovine  tillraic,  which  induces  more  intense 
reaction.  The  result  Avas  that  someiimcs  a  decided  positive 
reaction  occurred  after  the  one,  and  a  decided  or  mostly  negative 
reaction  after  the  other,  and  especially  in  visceral  and  surgical 
tuberculosis,  in  which  bo\  ine  reaction  is  remarkably  frequent ; 
Gebhardt,  lleim  and  John  have  also  made  such  experiments  with 
human  and  bovine  filtrates,  and  confirmed  the  difference  between 
the  human  and  bovine  type. 

The  last-named  investigators  had  ninety-one  positive  reactions 
in  140  children  and  live  adults.  The  human  and  bovine  papules 
were  of  the  same  size  in  fourteen  cases.  The  human  were  larger 
than  the  bovine  papules  in  twelve  cases.  The  bovine  were  larger 
than  the  human  papules  in  thirty-live  cases. 

In  Klose's  experiments  with  human  and  bovine  tuberculin, 
in  120  children  g'SS  per  cent,  reacted  only  to  human  ttiberctilin, 
5'34  per  cent,  only  to  bovine  tuberculin;  all  the  others  to  both 
tuberculins;  the  theory  of  Klose  that  he  had  to  do  here  with 
double  infection  is  unjustitied. 

Meisels  and  Progulski,  on  the  contrary,  in  parallel  experi- 
ments with  human  and  animal  tuberculin,  found  identical  reaction 
in  forty-seven  cattle  (see  also  A.  Calm's  similar  experiments) ; 
Clarke  and  Forsith  in  pulmonary  tuberculosis  generally  conhrnied 
both  forms  of  reaction.  The  experiments  of  Renlzler  and 
Blumenfeld  on  differentiating  cutaneous  reaction  are  not  at  present 
very  valuable. 

Experiments  on  animals  do  not  enable  us  to  recognize  any 
clear  difference.  Guinea-pigs,  whether  infected  with  the  human 
or  bovine  type,  reacted  to  small  quantities  of  both.  Those  infected 
with  the  avian  type  reacted  principally  to  the  same  type,  but  also 
to  human  and  bovine  tuberculin.  Even  animals  infected  with 
Timothy  bacilli  and  acid-fast  milk  bacteria  show  a  positive 
reaction,  although  perhaps  not  always  (Klemperer),  just  as  tuber- 
culin prepared  by  ]\Ioellers  from  Timothy  bacilli  (para-tuberculin) 
can  produce  positive  reaction  and  after-reaction  in  a  site  in  the 
eye  which  lias  responded  before  (Irimescu). 

For  the  present,  therefore,  the  differentiating  method  is  not 
applicable,  as  we  have  to  do  with  groups  of  symptoms,  botli  in 
subcutaneous  tuberculin  injection  and  in  serum  reaction. 


SECT  I  (J  N   VII. 

Prophylaxis. 


'Vo  bring-  into  1)r()acl  daylight  the  imjxiri.-iiKc  of  .sfrofulosis, 
especially  of  scrofulo-luberculosis  and  the  mode  of  comljaiing  it, 
it  would  be  natural  to  remove  from  the  rhetorical  armoury  the 
statement  that  the  whole  fight  against  tul)erculosis  rests  upon  its 
rational  attack  in  youth,  that  tuberculosis  is  a  child's  disease, 
Avhich  is  contracted  in  childhood,  and  which  must  be  combated 
then,  and  similar  arguments  which  we  have  often  heard  from 
Schlossmann  and  others. 

I  hold  this  standpoint  to  be  absolutely  false,  and  not  sup- 
ported by  any  exact  proof. 

If  V.  Beliring  brought  forward  the  statement  that  tuberculosis 
is  especially  contracted  in  youth  he  has  at  least  captivated  many 
doctors,  especially  children's  doctors,  thanks  to  belief  in  authori- 
ties— faith,  which  in  medicine  only  too  frequently  decides  the 
issue.  But  neither  v.  Behring  nor  his  followers  have  brought 
any  proof. 

All  that  has  been  spoken,  written,  and  affirmed  about  primary 
childhood  infection,  and  the  protection  gained  by  it  against 
further  later  infection,  is  up  till  now  unproven  from  first  to  last; 
it  is  mere  hypothesis  based  on  hypothesis,  for  where  are  the  exact 
proofs  ? 

The  facts  which  we  at  present  know  give  quite  a  different 
impression.  Let  us  only  call  to  mind  the  statistics  of  mortality 
from  tuberculosis  at  different  ages,  before  whose  iron  laws  we 
all  have  to  bow. 

Taking  an  average  of  sixteen  years,  the  mortalitv  from  tuber- 
culosis in  Prussia  was  as  shown  in  the  table  appearing  on  the 
following  page. 

We  see  from  this  that  a  child  in  its  first  year,  because  it  is 
closely  associated  with  its  mother,  has  about  the  same  death-rate 
from  tuberculosis — 26'4  to  22*94 — ^s  women  capable  of  bearing 
children,  respectively,  19' 18  to  32"8,  only  somewhat  lower,  because 


276 


SCROFULOSIS 


naiurallv  amongst  those  who  bear  chikhcn  heaUliy  are  more 
numerous  than  tuberculous  ones.  From  the  second  year,  when 
the  child  is  not  so  much  with  its  mother,  the  frequency  oi  tuber- 
culosis sinks  to  2()-So;  still  more  in  the  third  year  to  12-13  per 
10,000,  because  the  tuberculous  mother,  or  parents,  cannot  look 
after  the  child  .so  much,  perhaps  because  both  may  be  at  work. 
For  we  must  not  forget  that  the  deciding  vole  in  statistics  is  not 
cast  bv  the  well-to-do,  but  the  numbers  principally  represent  the 
conditions  of  the  working  classes,  the  population  with  an  income 
of  900  marks  (/,'43)  or  a  little  more. 


Amongst  10,000  living  of  the  age- 

class  in 

Amongst  10,000  persons 

of  the   sex    and   age   in 

question  in  the  category 

of  occupations  are 

Age 

question  dying  from  Tuberculosis 

Earning  their  living  and 

engaged     in     household 

duties 

Males 

Females 

Males        !    Females 

Males 

Females 

2 

3 

4                       5 

6 

7 

Under  i  year      

I — 2     years 

2—3        ..        

3—5        ..       

5-10      „       

10—15      ,,       

15—20      ,,       

20-25      ,,       

25—30      „       

30—40      ,,       

40-50      , 

50—60      ,,       

60—70      ,,       

70—80      ,,       

Over  So      ,,       

26-4 
20  89 

12-45 

6-87 

4-52 

4-89 

17-63 

32-32 

36-62 

43'54 
54-70 
75-88 

99-65 
69-30 
26-21 

22-94 
20-85 

I3'54 

7-95 
6-00 

8-93 
19-80 

25-34 
32-82 

37-54 
38-10 

49-52 
68-33 
45-69 
19-69 

-      8-85 

■     3468 

10-44 
29-14 

402 

8966 
■        9685 

9781 

97>5 
9378 
7989 

}     4658 

256 

6672 
4659 

2173 
2403 
2776 
2436 

1425 

From  the  third  to  the  fifth  year  the  child  of  the  working 
classes  is  but  little  with  its  relations,  who  may  be  tuberculous,  for 
they  are  either  at  work  or  in  hospital,  and  the  child  is  more  out  of 
doors  during  the  day,  whilst  (as  I  believe  I  have  conclusively 
proved  in  another  place)  the  danger  is  not  so  great  at  night  (see 
Cornet,  "Die  Tuberculose,"  second  edition,  p.  399).  Accord- 
ingly, the  death-rate  from  tuberculosis  sinks  6-8 — 7-9  per  10,000, 
and  is  on  the  whole  somewhat  higher  in  girls  who  are  tied  more 
closely  to  their  mother's  apron  strings,  and  sit  more  at  home. 

The  frequencv  of  tuberculosis  becomes  still  less  when  the 
child  is  kept  awav  from  tuberculous  adults  by  school.  From  the 
fifth  to  tenth  vear  il  is  only  4-3  to  6-0.  From  the  tenth  to  fifteenth 
year  4*9  to  8-9  per  10,000. 

Clinical    investigations    as    to    the    spread    of    tuberculosis 


I'KOI'IIM.AXIS  277 

amoiif^^sl  scliool  (  liilflifii  rorrcspond  will)  litis.  l\crr  found 
am()n<^"sl  1,070  scIkkiI  (Inldn'ii  siirr-  signs  of  pulmonary  tubercu- 
losis in  only  ciglil  (05  per  ccni.).  I  lay  also  only  0*5  per  cent. 
Lecky  and  Morton,  in  lirigliion,  037  per  crnt.  We  must  not 
take  the  positive  reaction  which  every  inoffensive  bfjvine  focus 
gives  as  a  standard,  for  iliis  would  lend  us  astray  (see  pp.  ifj 
and  2^()). 

in  ihc  last  \('ars  of  childhood,  from  10  to  15,  we  notice  a 
slight  rise  of  tuberculosis,  for  from  the  ages  of  13  to  15  employ- 
ment and  apprenticeship  begin  (as  shown  by  columns  6  and  7). 

From  the  twentieth  vear  the  frer|uency  of  tuberculosis  rises 
continually  to  the  sexcnlieth  vear,  when  it  even  attains  in  males  99 
per  10,000;  with  women  it  rises,  as  we  percei^•e  in  columns  6  and 
7,  much  more  slowly,  because  they  have  to  earn  their  living  less 
often  than  men.  If,  then,  we  hold  the  thef)ry  that  infection 
principally  takes  place  in  childhood,  then  the  child's  organism 
must  possess  a  most  extraordinary  power  of  resistance  to  the 
bacilli,  for,  in  spite  of  the  infection  supposed  to  have  been  taken, 
so  few  children  die  of  tuberculosis. 

On  the  other  hand,  morbid  anatomy  and  clinical  experience 
teach  us  that  infection  in  childhood  is  most  dangerous,  that  nearly 
all  tuberculosis  in  infancy  ends  fatally,  that  the  bacilli  in  the  child's 
body  exhibit  a  decided  tendency  to  disseminate,  and  even  to  lead 
to  general  miliary  tuberculosis;  herein  lie  clear  contradictions 
between  experience  and  hypothesis,  which  are  dilTficult  to  solve. 

The  gradual  rise  in  the  frequency  of  tuberculosis,  from  the 
twentieth  to  the  seventieth  year,  is  quite  explicable  to  us,  for  the 
more  battles  the  soldier  has  gone  through,  so  much  the  more 
probable  is  it,  on  an  average,  that  a  bullet  will  strike  him,  and  the 
longer  one  is  at  a  trade,  the  more  natural  is  it  that  he  will  be  in 
close  contact  with  tuberculous  persons,  and  that  he  will  at  last  be 
infected. 

Comby  explains  the  increasing  frequencv  in  advancing  vears 
by  the  simple  fact  that  older  persons  are  for  a  longer  time  exposed 
to  the  numerous  opportunities  of  infection,  which  agrees  with  the 
instance  I  have  so  often  brought  forward,  that  1,000  soldiers  who 
have  gone  through  ten  battles  have,  as  a  rule,  more  wounds  and 
scars  to  show  than  after  the  first  battle. 

But  as  soon  as  a  man  after  70  years  retires  from  industrial 
activity  the  death-rate  from  tuberculosis  sinks  from  99  to  69.  and 
even  to  26,  and  with  females  to  19;  in  other  words,  the  frequencv 
in  those  confined  to  the  house  is  the  same,  whether  thev  be 
children,  women  capable  of  bearing  children,  or  old  people  who 
can  no  longer  get  out  much.     \o  attempt  has  yet  been  made  to 


278  SCROFL'LOSIS 

coniradicl  this  by  explaining  the  higli  morialiLy  from  tuberculosis 
in  later  life  from  the  standpoint  of  infantile  infection. 

We  must,  if  we  keep  to  facts,  flatly  decline  to  recognize  that 
infection  and  tuberculosis  in  the  child  has  any  great  influence  on 
the  tuberculosis  of  adults. 

At  the  same  time  there  is  reason  to  combat  tuberculosis  and 
scrofulosis  in  children  for  its  own  sake. 

The  prophylaxis  of  scrofulosis  has  the  greater  prospect  of 
success  the  more  the  conviction  gains  ground  that  for  this  disease, 
especially  in  its  severe  tuberculous  form,  neither  descent  nor  race 
cause  any  special  susceptibility,  but  certain  external  conditions, 
are  distinctly  necessary  to  cause  it ;  the  more  we  seek  its  cause, 
not  in  man  alone,  but  outside  him,  the  less  shall  we  lay  the 
responsibility  on  things  over  which  we  have  only  slight  influence 
or  none  at  all. 

I  should  like  to  offer  the  following  opinion  of  \''irchow,  in 
answer  to  the  one-sided  and  exaggerated  emphasizing  of  predis- 
position :  "  But  one  should  not  overlook  the  fact  that  even  with 
existing  predisposition  it  is  only  the  opportunity  for  the  cause 
which  produces  disease,  therefore  these  opportunities  should  be 
watched  over  as  carefull}'  as  possible."  The  precautions  against 
infection  and  predisposition,  against  pyogenous  and  tuberculous 
scrofulosis  are  in  many  cases  the  same  ;  we  mav  therefore  leave  out 
a  separate  and  systematic  consideration  of  them  which  otherwase 
would  be  demanded.  The  precautions,  though  apparently  only 
directed  against  predisposition,  before  the  occurrence  of  bacteria, 
acted  for  the  most  part  (though  perhaps  unconsciously)  against 
bacteria  and  against  infection.  For  example,  air  and  light 
increase  the  power  of  resistance  of  the  body,  and  they  are  also 
incontestablv  the  best  means  of  destroying  or  keeping  off  certain 
bacteria  in  our  environment. 


CHAPTI'R    I. 

THE   CHILD   IN   THE   FAMILY. 


Thk  general  interest  in  the  bringing  up  of  healthy,  strong 
children  which  have  powers  of  resistance,  makes  it  necessary  for 
us  doctors,  e\en  if  we  cannot  entirely  fathom  the  great  influence 
of  heredity,  to  do  what  we  can  to  hinder  the  marriages  of  weakly  or 
delicate  persons,  of  those  who  are  too  young  or  too  old,  the  pro- 
pagation by  such  individuals,  and  births  following  too  rapidly  one 
after  the  other,  on  account  of  the  conseciuent  exhaustion  of  the 
mother — in  truth  sometimes  only  a  pious  wish,  as  the  doctor  does 
not  bring  his  conviction  to  bear  with  sufficient  emphasis.  Concep- 
tion under  the  foreQoing  exhausting  conditions  lavs  still  heavier 
duties  on  the  pregnant  woman.  More  than  others,  in  this  condition 
she  must  during  pregnancy  avoid  as  much  as  possible  all  that  may 
further  weaken  the  embryo,  all  bodily  and  mental  harm,  all  extra- 
vagance and  excess;  she  must  do  her  best  to  make  her  life  follow 
hygienic  demands,  to  keep  up  her  strength — and  thus  also  that 
of  the  child  she  bears — by  proper  and  sufficient  nourishment  and 
fresh  air,  avoiding  exertion  that  weakens,  and  all  clothing  that 
may  obstruct.  If  she  suckle  the  child  herself  later,  this  care  must 
naturally  be  extended  during  the  period  of  lactation. 

Air,  light,  cleanliness  and  nourishment  are  the  chief  weapons 
which  we  have  to  use  to  avoid  scrofulosis,  especiallv  with  those 
children  who,  from  the  history  of  their  parents,  brothers,  and 
sisters  (scrofulosis,  tuberculosis  in  the  family,  or  weakening 
diseases  of  the  parents  at  the  time  of  conception),  or  their  own 
antecedent  circumstances,  lead  one  to  fear  scrofulosis  for  them  in 
the  future.  As  a  matter  of  precaution,  even  in  families  to  which 
hitherto  suspicion  has  not  been  attached,  rigid  attention  should 
be  paid  to  these  four  cardinal  demands  for  general  hvgienic 
reasons. 


2So  SCROFULOSIS 

AIR,   LIGHT,   CLEANLINESS. 

The  (.lemaiul  tor  fresh,  good  air  is  fouiuled  on  iis  greater 
freedom  troni  genns  and  its  inchreci  inxigoraiing  influence  on 
nourishment.  As  the  air  of  the  house,  enclosed  within  four  walls, 
even  untler  the.  best  circumstances,  can  never  be  so  pure  as  the 
ojDen  air,  children  should  be  accustomed  at  an  early  date  to  fresh 
air,  as  far  as  climate  and  weather  permit,  and  doctors  should 
overcome  the  objections  of  too  anxious  mothers. 

According  to  the  old  rule  of  v.  Amnion,  in  spring  and 
simimer  a  child  can  be  in  the  air  at  about  ten  days  after  birth 
(a\-oiding  bright  sunshine),  in  winter  six  lo  eight  weeks  after 
birth — at  first  onlv  for  half  an  hour  or  an  hour.  Up  to  the  second 
vear  a  temperature  of  2°  of  frost,  and  from  ,^  to  6  years  a  tem- 
perature of  5°  of  frost  must  be  axoided,  or  onl\-  allowed  for  a 
short  time — laws  \vhich,  with  proper  clothing  and  ^\hcn  there  is 
no  wind,  may  be  relaxed  to  a  certain  degree. 

The  longest  possible  enjoyment  of  fresh  air  is  also  to  be 
recommended  on  account  of  the  sunlight,  the  bactericidal  powers 
and  stimulating  influence  on  nourishment  and  metabolism  of 
which  are  well  known,  to  say  nothing  of  its  effect  in  transmitting 
chemical  ravs,  a  subject  which  has  as  yet  been  little  investigated. 

But  li^•ing  in  the  open  air,  even  in  a  favourable  climate,  and 
much  more  in  the  colder,  more  inclement  northern  countries,  is 
limited  as  to  time.  Therefore,  care  must  be  taken  that  light  and 
air  have  free  entrv  to  the  dw'elling  house,  which  plays  a  much 
more  important  part  in  the  life  of  the  child  than  in  that  of  the 
adult  .who  li\es  more  outside  the  home.  Where  the  means  allow 
of  a  choice  the  nursery  should  always  be  roomy,  high,  facing  south, 
south-east,  south-west  or  west  ;  a  north*  aspect  should  never 
be  chosen,  but  an  aspect  which  has  for  al  least  one  hour  in  the 
day  direct  sunshine,  and  of  course  in  a  dry  house,  not  in  a 
newly-built  one.  But  how  frequently  is  this  law^  disobeyed,  even 
when  there  is  no  necessitv,  especially  amongst  the  middle  classes? 

How  dearly  must  many  a  mother  pay  for  the  bright  and 
beautiful  situation  of  her  little-used  drawang-room,  with  the 
scrofula,  even  with  the  life  of  her  children  w'ho  have  to  occupv 
less  advantageously  situated  rooms.  Hygienic  demands  suffer 
shipwreck  most  frequently  from  our  bad  social  conditions,  which 
crowd  families,  especially  those  in  which  there  are  manv  children, 
into  small,  dark  rooms  looking  out  on  narrow  streets  or  courts. 
Even  a  good  current  of  air,  to  which,   unfortunately,  the  poorer 

*  I  refer  again  to  the  evidence  of  increased  mortality  amongst  those 
living  on  the  north  side  of  a  street. 


l'KOI'IIN'l,AXIS  281 

classes  arc  very  diik  li  npiioscd,  in.'i\-  piiiih  ilif  air  an<l  lower  thf; 
amount  of  germs  (  nni.-iimd  in  ii  ;  a  1  limnni^li  improvement  iS 
hardly  lo  he  oUlaiiicd  wiMioiii  \\\c  lidp  ot  the  (government,  witli- 
oiil  a  law  b(;aring  on  liir  ii vL;i<'ni(:  <  1  mdii i(jii  oi  dwelling-houses. 

Cleanliness  in  iis  mosi  far-rca(  hing  sense,  in  the  child  as 
well  as  in  its  sui  loiindings,  is  one  ol  ilic  most  important,  if  not 
the  most  imporlaiil,  means  of  avoiding  ilie  production  of  scrofu- 
lous changes  by  the  entry  and  settlement  of  pus  cocci  or  tubercle 
bacilli.  Scrofulosis  has  been  called,  and  not  enlirely  wrongly, 
a  "dirt  disease."  In  families  where  cleanliness  reigns  we  rarely 
llnd  the  severe  forms  of  pyogenous  scrofulosis  which  are 
frequently  met  with  in  dirty  liouses. 

The  child  must  front  its  birth  be  bathed  daily  (in  water  at 
first  35°.,  later  t,t,°  lo  30°),  and  then  swilled  with  colder  water, 
and  thoroughly  rubbed. 

Special  care  must  be  tak'en  to  k'eep  ilie  natural  covering  of 
the  body  as  intact  and  free  from  germs  as  possible.  A  scalp 
which  has  a  tendency  10  form  dandriff  must  be  carefully  cleansed 
with  soap  and  water,  sc~urf  softened  beforehand  by  means  of  (jlive 
oil,  glycerine,  or  \()lk  of  egg,  and  the  hair  v.ell  brushed  and  cared 
for.  In  cases  of  seborrhcea  sicca,  to  remove  the  grease,  the  skin 
must  be  rubbed  with  spiritus  saponis  alkalinus  or  fluid  tar  soap, 
washed  with  warm  water,  and  then  covered  with  an  ointment 
such  as 

B    Zinc.    oxyd.              ...  ...  ...  6'o 

Sulph.    prsecip.         •••  .         •••  ■■■  4'o 

Terras  silic.              ...  ...  ...  2"o 

Adip.  benz.               ...  ...  ...  28'o 

M.  f.  pasta.      (I 'una.) 

Pedictdi,  which  ma_\-  indirectly  cause  infection  bv  scratching, 
are  removed  by  petroleum,  balsam  of  Peru,  or  sublimate  solution 
(i  in  300). 

To  protect  tender  parts  from  becoming  sore  (intertrigo)  from 
the  faeces,  urine,  or  perspiration,  they  must  be  cleansed  several 
times  a  day  with  cold  water  and  pow'dered  (especially  where  the 
skin  forms  folds,  in  fat  thighs,  in  the  neck,  (^c).  Napkins  must 
be  constantly  changed,  and  washed  after  changing,  not  onlv 
dried.  A  child  must  be  accustomed  to  regularitv  and  clean- 
liness in  emptying  the  bladder  and  bowels.  It  must  be 
taught  early  to  blow  its  nose.  \>ry  often  children  close  the 
nose  with  the  handkerchief  by  blowing  it  awkwardlv,  which 
favours  catarrh  of  the  nose,  and  by  so  doing  mucus  is  easilv 
forced  into  the  Eustachian  tube  and  the  middle  ear.  It  is 
very  important  to  accustom  a  child  to  gargling  and  care  of  the 


282  SCROFLLOSIS 

teeth  at  an  early  age;  a  child  nuisi  early  be  laught  to  clean 
the  teeth,  especially  after  every  meal,  and  they  must  be  regularly 
examined  (see  p.  142  :  The  Danger  of  Carious  Teelh).  Carious 
teeth  must  be  treated,  and  if  necessary  removed;  the  use  of 
the  samecomb,  towel,  and  even  tnoih-hrush  (I)  is  lo  be  avoided 
as  far  as  possible. 

Acne  pustules,  which  appear  in  older  children,  and  which  by 
scratching  sometimes  become  a  starting  j^itint  of  lu]iotis  changes, 
must  be  emptied  aseptically  and  treated. 

As  with  the  body,  so  also  with  the  clothing  and  bed  linen 
the  greatest  care  must  be  used.  It  must  all  be  placed  in  the  sun 
as  frequently  as  possible,  this  being  the  cheapest  disinfectant. 
For  children,  white  or  light  materials  are  to  be  preferred,  because 
dirt  can  better  be  seen  on  them,  and  therefore  greater  cleanliness 
is  enforced. 

According  to  the  investigations  of  Roepke  and  Busch,  twenty- 
four  hours'  soaking  in  a  2  per  cent,  solution  of  lysol  is  to  be 
recommended  for  the  certain  disinfection  of  contaminated  (tuber- 
culous) linen.  Amongst  the  poorer  classes,  the  beds  in  which 
people  have  died  are  slept  in  without  precautionary  disinfecting 
measures  being  taken,  and  thus,  especially  in  tuberculosis,  the 
bacilli  are  further  disseminated.  To  cleanse  such  beds,  the 
methods  employed  in  the  so-called  factories  for  cleansing  beds  do 
not  by  any  means  sufifice.  Once  I  had  a  bed  which  was  infected 
with  tuberculous  sputum  "  cleaned  "  six  times  one  after  the  other, 
and  each  time  took  tests,  which  I  inoculated  into  guinea-pigs.^ 
Each  time,  from  the  first  to  the  sixth,  the  guinea-pig  became 
tuberculous.  Reliable  disinfection  can  only  be  made  by  steam, 
by  which  the  feathers,  if  they  be  kept  away  from  the  direct  inlet, 
are  not  in  the  slightest  injured,  but  fluff  out  beautifully.  I  mention 
this  especially  in  contradiction  of  a  statement  by  Schablowski. 

Not  only  the  child,  but  its  environment,  must  be  kept 
studiously  clean  ;  the  nursery  must  be  cleaned  dailv  and  aired  at 
least  twice  a  day,  the  child  during  that  time  being  taken  else- 
where, and  only  allowed  to  enter  the  room  again  one  hour  after 
cleaning,  so  that  the  dust  which  has  been  stirred  up  may  be  laid 
before  it  returns.  The  floor  must  be  kept  specially  clean,  as  little 
children  crawl  about  a  great  deal  and  come  closely  in  contact  with 
it.  It  must  be  wiped  with  a  damp  cloth,  and  should  not  be 
trodden  with  dirty  boots  or  shoes.  The  best  floor  covering  is 
linoleum,  because  it  is  easily  cleaned,  is  soft,  and  does  not  crack; 


'  G.   Cornet  :    "  Dissemination   of   Tubercle   Bacilli   outside   trie   Body." 
Zeitschrift  fiir  Hygiene,  vol.  v,  p.  328,  1888. 


I'ROI'llYLAXfS  283 

curtains,  carpels,  upholslfrcd  fiiriiiinrc,  and  siicli-lik'-  dust  traps, 
must  be  done  away  willi  as  lar  as  possible  in  children's 
a[)arlnienls. 

'To  avert  the  danger  arising  from  the  habil  childrcMi  have  of 
touching  everytiiing,  of  putting  their  dirty  lingers  in  moutli  and 
nose,  and  making  I  heir  faces  dirty,  tlie  mouth  and  hands,  and 
especially  liie  nails  and  folds  of  the  nails  must  be  constantly 
cleansed,  especially  before  meals  (in  infants  the  mouth  must  be 
cleaned  with  a  wet  linen  rag  after  every  meal).  Little  excoriations 
which  often  appear  on  the  tender  skin,  after  being  cleansed  anti- 
septically,  must  be  closed  with  collodion.  We  have  seen  above 
(p.  137)  how  often  the  little  hands  are  soiled  with  tubercle  bacilli. 
Toys,  as  far  as  possible  washable  ones,  must  be  kept  clean  ; 
smaller  objects,  such  as  beads,  beans,  peas,  coins,  which  they 
delight  to  push  into  (he  nioulh,  nose  and  ears,  must  be  kept  out 
of  reach,  besides  endeavouring  to  correct  this  bad  habit  as  early 
as  possible. 

The  protective  frame,  recommended  by  Peer,  is  suitable  for 
children  as  soon  as  they  can  sit  up  alone,  that  is,  from  the  fifth 
to  sixth  month,  till  the  second  or  third  year  if  there  be  room 
enough ;  it  is  similar  in  shape  to  that  mentioned  by  the  old 
Viennese  doctor,  Golis,  to  teach  children  to  walk  without  incur- 
ring any  danger. 

The  protective  frame  is  made  of  wood  70  to  75  cm.  high, 
about  100  to  150  cm.  long  and  wide,  the  sides  of  which  are  joined 
together  with  hinges  and  hooks,  representing  a  frame  of  wood 
filled  in  with  rails,  made  with  thin  laths  of  wood  or  strips  of 
linoleum  about  6  cm.  apart;  the  floor  inside  this  square  enclosure 
is  covered  wdth  a  mattress,  exactly  fitting,  with  a  waterproof  cover 
or  tightly  covered  with  a  white  washable  blanket. 

This  arrangement  has  the  advantage  that  the  children  may 
be  left  alone  in  it  without  fear  of  danger,  and,  it  is  noted  by  Golis, 
their  muscles  are  exercised  and  their  walking  powers  are  early- 
developed,  as  the  children  can  move  about  freelv.  But  the  chief 
advantage  lies  in  the  fact  that  the  children  are  isolated,  and 
thereby  the  possibilitv  of  infection  reduced. 

NOURISHMENT. 

In  many  cases  of  scrofulosis  there  is  a  probable  connection 
between  the  disease  and  mistakes  in  nourishment ;  from  what  has 
been  said  above  (pp.  50  and  166).  the  prophylaxis  must  be  looked 
at  from  three  points  of  view. 

(i)  The  food  chosen  must  be  appropriate  and  sufficient,   so 


284  SCROFULOSIS 

that  it  is  capahU'  o\   leading;  lo  ilic  tlevrlopiiicnl  of  normal  power 
in  the  \-outhful  body. 

(2)  It  must  be  suited  t(»  the  capal)iHiies  of  the  ciiild's  digestive 
organs  for  the  time  being,  lioih  in  (|uaniity  and  quaHty. 

(3)  It  must  not  be  in  a  state  of  decomposition,  and  must  be 
free  from  germs,  absohitely  free  fnmi  pathogenic  germs. 

Mother's  Milk. 

Tht'  ]3roper  ndurishnuMil  for  infants  is,  as  a  ruie,  that  which 
Nature  has  iierseU"  pri)vided  in  the  breast  of  a  heahhy  mother; 
by  breast  feeding  we  remove  a  series  of  difficuhies  which  are  other- 
wise unavoidable.  It  is  the  duty  of  a  doctor  to  induce  the  mother 
to  suckle  her  child  herself  if  it  be  in  any  way  possible. 

It  is  not  the  place  here  to  enter  with  more  detail  into  the 
preparation  of  the  lireasls  from  the  sixth  monlh  ol  jDregnancy,  tor 
the  duties  the\'  have  to  undertake,  on  tlie  conduct  and  mode  of 
life  of  a  nursing  mother,  her  nourishment,  and  the  avoidance  of 
all  bodilv  and  mental  excitement.  Besides  the  cases  where  a 
mother  cannot  suckle  her  infant  on  account  of  defective  develop- 
ment of  the  breasts,  or  for  want  of  milk,  she  must  not  do  so  when 
there  is  great  weakness,  severe  anaemia,  tuberculosis,  recent 
syphilis,  or  severe  diseases,  because  she  would  only  use  up  her 
own  strength  and  endanger  the  infant  by  doubtful  food  (toxin 
contents  of  milk)  or  infection  (see  Deutsch  and  the  opposing 
opinions  of  Biederl,  Czern\-Schlossmann  ;  toxin  content.  Rappin 
and  Fortineau). 

In  these  cases,  where  circimisiances  perniit,  a  wet  nurse 
should  take  the  place  of  the  mother  as  the  most  natural  and  best 
substitute.  It  is  not  the  place  here  to  speak  of  the  ethical  side 
of  the  question  of  wet  nurses.  With  a  child  who,  from  his 
descent,  may  be  suspected  to  be  scrofulous,  one  must  be  more 
careful  than  with  another  to  choose  a  wet  nurse  who  is  strong 
and  not  too  old,  who  was  confined  at  abotil  the  same  time  as  the 
mother,  or  in  any  case  has  given  birth  to  her  child  longer  than 
six  weeks.  Care  must  be  taken  b}  most  thorough  examination 
that  there  is  no  suspicion  of  tuberculosis,  scrofulosis,  svphilis,  or 
other  weakening  affections.  The  result  of  Wassermann's  reaction 
insures  against  svphilis.  Thomsen  requires  that  the  serum  as 
well  as  the  milk  shall  be  examined.  The  claim  for  tuberculin 
inoculation,  in  itself  justifiable,  involves  some  doubt,  as  com- 
pletely healed,  inoffensive  (bovine)  lesions  react  positively,  and 
thereby  many  wet  nurses  would  be  excluded  who  might  be 
allowed  to  suckle  without  fear  of  conseciuences.     The  milk  of  the 


I'KOI'IIYLAXIS  285 

wcL  nui'.s(;  inusL  answer  I  he  demands  as  lo  f|n.'iniiiy  and  (jn;dit\'. 
One  must  not  neglect  (:()nvin(  in^-  (incs<-||,  hy  insp'-r  tion  <,\  thf 
foster  child,  of  its  thriving-  and  regular  increase  in  weight,  lie- 
sides,  the  milk  of  the  nurses  can  be  clu;mically  and  microscopically 
examined,  but  many  children's  s[V'(ialisls  (lleubner  .-md  C/.<:rny) 
consider  this  unnecessary. 

Cows'    Milk. 

If  nourishmenl  b}-  a  nurse  cannot  be  carried  r)Ul,  or  if  the 
mother's  (or  ihe  nurse's)  milk'  How  too  sUnvly,  as  known  by  the 
motions  of  the  child  being  scanty,  Ijrown  and  green  instead  of 
yellow,  and  by  the  weight  of  the  child  before  and  after  feeding, 
then  nourishment  by  cows'  milk  with  a  bottle  must  be  resorted  to 
as  a  substitute  or  in  addition.  There  are  so  many  natural  advan- 
tages in  this  that  it  becomes  a  very  important  duty  to  assure 
ourselves  of  the  benefit  resulting  from  it  on  scientific  lines,  the 
more  so  as  the  slightest  neglect  with  children  suspected  of 
scrofulosis  might  have  very  serious  consequences.  One  should 
endeavour  at  all  costs  that  at  least  for  the  first  week,  the  most 
serious  time,  nourishment  by  mother  or  nurse  should  be  obtained; 
then  should  a  change  be  absolutely  necessary,  at  first  only  one 
meal  of  cows'  milk  may  be  substituted,  then,  according  as 
necessary,  two  or  three  may  be  given ;  but  breast  milk  should  be 
given  as  long  as  possible,  at  least  in  the  first  half  year. 

After  asses'  milk,  which  on  account  of  the  difificulty  of  obtain- 
ing it  can  hardly  be  taken  into  consideration,  cows'  milk  comes 
next  in  quality. 

To  render  cows'  milk  more  similar  in  its  composition  to 
human  milk,  and  more  suited  to  the  child's  power  of  digestion, 
one  must  add  two  parts  of  water  to  one  part  of  milk  in  the  first 
month ;  in  the  second  and  third  months  equal  quantities  of  milk 
and  water ;  in  the  third  and  fourth  months  tw;o  parts  of  milk  to  one 
of  water;  after  that  pure  milk.  To  every  100  c.c.  add  one  tea- 
spoonful  of  milk-sugar,  or  Soxhlet's  nutritive  sugar  up  to  10  per 
cent,  of  the  mixed  milk.  Instead  of  water,  a  verv  suitable  gruel 
wdiich  may  be  given  is  made  of  two  teaspoonfuls  of  oats,  wheat, 
barley,  or  maize  meal  (mondamin)  mixed  with  half  a  litre  of  water 
and  boiled.  The  quantity  for  the  day,  in  from  five  to  six  meals, 
is  from  400  c.c.  in  the  first  month  to  800  or  900  c.c.  in  the  fourth 
month.  Czerny  (see  below)  increases  from  five  times  100  c.c.  to 
four  times  250  c.c,  and  one  supplemented  meal  of  soup  at  the  end 
of  the  first  year.  U^ndiluted  milk  has  been  given  from  birth;  the 
results  of  this  are  not  vet  definite. 


286  SCROFULOSIS 

The  harmful  \ariatinn.s  in  ihe  i-onsiiluenls  in  consequence  of 
changes  in  ihe  niilkiny;-,  ihc  race  or  age  of  animals,  may  be 
lessened  and  neutralized  bv  using  milk  from  several  animals. 

A  few  years  ago  preference  was  given  in  general  lo  dry  feed- 
ing for  milch  cows,  and  it  was  thought  lo  be  the  best  means  for 
assuring  good  infant's  milk  free  from  germs.  According  to 
present  opinions,  we  think  ii  much  more  imporlant  that  fodder 
should  be  chosen  containing  ihe  proper  prt)porlions  of  nourish- 
ment, and  sudden  change  of  feeding  should  be  avoided. 

Besides,  living  in  slables  with  dry  food  has  many  disadvan- 
tages over  being  in  the  helds,  and  especially  it  increases  the 
danger  of  infection  by  bovine  tuberculosis. 

We  mav  presume  that  ii  is  well  known  that  the  milk  of 
diseased  animals  is  inferior  and  oflen  very  harmful  for  infants. 
Scrofulosis  and  tuberculosis  are  the  two  diseases  the  prevention  of 
which,  in  milch  cows,  has  chiefly  to  be  considered,  and  the  wide 
spread  of  which  we  have  demonstrated  by  statistics  above 
(see  p.  1 08). 

For  obtaining  milk,  especially  milk  for  children,  only  such 
animals  should  be  chosen  as  are  completely  and  most  certainly 
free  from  bovine  tuberculosis ;  this  is  a  demand  which  it  is  often 
difficult  to  fulfil  owing  to  the  prevalence  of  bovine  tuberculosis. 

As  a  rule,  tubercle  bacilli  are  only  transmitted  to  the  milk 
when  the  cows  suffer  from  tuberculosis  of  the  udder.  But 
tubercle  bacilli  have  been  found  in  cows  apparently  free  from 
tuberculosis  of  the  udder,  so  that  the  demand  that  all  animals 
with  any,  even  closed  tuberculosis,  shall  be  excluded,  as  milch 
cows,  especially  for  children,  appears  to  be  justified. 

Only  those  animals  afford  a  complete  guarantee  which  with 
appropriate  and  repeated  tuberculin  injection  show  no  reaction, 
and  which  thus  proclaim  their  immunity.  There  is  no  doubt  that 
by  tuberculin  reaction  man}'  animals  are  excluded  which  give  no 
tuberculous  milk.  Thus,  for  example,  amongst  eighty-four  cows 
which  reacted  with  Bolle,  it  was  only  the  milk  of  one  single  cow 
which,  on  further  injection,  produced  tuberculosis.  On  account 
of  the  variations  which  animals  exhibited  in  reaction,  the  question 
was  raised  whether  a  monthly  examination  of  all  cows  bv  a 
veterinary  surgeon  and  testing  of  the  mixed  milk  would  not  be 
sufficient. 

But  that  this  method  is  not  an  entire  substitute  for  tuberculin 
injection  for  clinical  examination  does  not  suffice,  even  if  clinically 
healthy  animals  have  tubercle  bacilli  in  their  milk  only  excep- 
tionally (Yong).  The  transmission  of  tubercle  bacilli  to  the 
milk  by  one  single  cow,  whose  disease  had  escaped  notice,  can 


KOI'IIVI.AXIS 


287 


inl'ccl    llic   wliolc  ol    llif  (ini\c(l)   milk  ol    ili''  oilicrs  fMfjfllcrs  aiifi 

R.  Koch)- 

We   niiisl    kcf-p    l<>   ill'"   <l''maii(l    lor    I  iiljcrciiliii    injections,   at 

least  for  cows  ,i4-i\inK  'I'i"^  ''"'  inl'in'^,  \Nlii'  li  is  '^^^'^  •'^old  at  a  very 

hij^h   price. 

I  Inlorliinaleh-,  inain-  dairymen  (;nly  usft  the  Inberculin 
injection  as  an  adveri  isemeni  and  for  obtaining'  lii^di  prices; 
many  cattle  dealers  often  profil  by  the  fact  that  cattle  become 
accuslomed  to  inberculin  to  a  certain  cU'^rcc,  and  after  a  short 
time  there  is  no  reaction,  no  increase  of  temperature,  and  the 
animals  appear  healthy.  lUit  we  can  protect  ourselves,  wjien  we 
suspect  a  previous  injection  made  with  the  intention  of  deceiving; 
us,  by  empl()vin<4-  a  double  dose,  and  taking:  the  temperature  every 
two  hours  (klimmer  and  Iviessig) ;  further,  after  testing  the 
condition  of  the  animals,  repealing  the  test  after  tiiree  or  six 
months,  and  only,  slunild  this  prove  negative,  allowing  the  animal 
to  come  into  the  milking  shed. 

According  to  Klimmer,  no  tuberculin  habit  is  formed  with 
the  conjunctival  test,  and  liitherto  no  particular  harm  has  been 
observed  as  resulting. 

Besides  tubercle  bacilli,  the  contamination  of  milk  by  other 
bacteria  is  of  great  importance  in  scrofulosis.  To  say  nothing 
of  dilution  by  the  addition  of  (bad)  water  and  chalk  and  plaster 
of  Paris,  which  the  inspectors  have  to  strive  against  by  frequent 
supervision,  the  milk  may  become  contaminated  by  the  excrement 
of  the  cows,  or  later  by  dirty  vessels,  or  infection  from  the  air. 
Once  in  the  milk  thev  prohferate  rapidly  in  so  excellent  a  culture 
medium,  and  reduce  the  nourishment  of  the  child  Idv  the  decom- 
position set  up  bv  them  and  their  products,  and  are  a  direct  menace 
by  their  invasion  to  the  tender,  penetrable  mucous  membrane,  so 
capable  of  absorption,  together  with  the  lymph  glands  belonging 
to  them  (causing  tabes  mesenterica  non-tuberculosa). 

It  is  most  necessary,  therefore,  from  the  very  beginning  to 
endeavour  as  far  as  possible  to  pre^-ent  the  entry  of  germs  into  the 
milk. 

To  avoid  this  danger,  as  far  as  mav  be,  there  must  be 
extreme  cleanliness  in  the  whole  of  the  dairv  farm,  rapid  removal 
of  excrement,  the  prevention  as  far  as  possible  of  dust  when  bring- 
ing in  the  germ-laden  dry  fodder,  cows  must  be  milked  in  a  place 
free  from  germs,  punctilious  cleanliness  in  milking,  previous 
cleaning  of  the  udder  and  the  bush  of  the  tail,  and  the  milkers, 
clean  vessels,  imrnediate  thorough  cooling  of  the  milk  after  milk- 
ing, cool  temperature,  both  in  transport  (in  sterilized  cans  or 
bottles)  and  when  kept. 


288  SCROFULOSIS 

In  modern  model  dairies  milking  takes  place  in  antiseptic 
sheds  under  antiseptic  precautions,  by  emplovi'S  especially 
trained,  and  prepared  antisepticallv  ;  ihe  milk  is  pul  al  once  into 
bottles,  and  immediately  brought  lo  a  low  temperature. 

Only  milk  taken  from  animals  proved  to  be  healthy,  and 
collected  with  antiseptic  precautions  can  be  considered  as  com- 
pletely free  from  bacilli  and  free  from  all  objections,  so  that  it  can 
be  taken  by  children  in  its  raw  state  or  boiled.  But  the  cost 
entailed  bv  such  precautions  is  nuicli  loo  high  at  present  to  be 
afforded  for  the  greater  number  of  our  children;  besides  which, 
the  great  advantages  gained  l)y  the  use  of  raw  milk  are  not 
entirely  uncontested  (A.  Keller  and  Planteng). 

For  the  greater  number  of  our  children  we  must  be  content 
if  the  milk  is  obtained  at  least  as  free  as  possible  from  germs, 
bv  low  temperature  and  sterilization,  and  comes  to  us  as  little 
changed  in  condition  as  may  be. 

Sterilized  milk  usually  ol)tained  in  shops  is,  as  a  rule,  healed 
in  bottles  to  65°  or  75°  C.  for  thirty  minutes,  or  to  70°  C.  for 
fifteen  minutes,  or  in  other  dairies  to  100°  C.  for  ten  minutes. 
Unfortunately,  the  repeated  observation  of  such  milk  proves  that 
the  proceeding  is  not  always  carried  out  sufficiently  conscien- 
tiously. 

If  the  milk  is  not  bought  at  a  model  dairy,  where  it  is 
sterilized  or  pasteurized  and  put  into  closed  bottles,  it  must  at 
least  be  divided  at  once  into  portions  at  home,  boiled  for  quite 
five  minutes,  then  kept  in  a  cool  place,  and  consumed  within 
twentv-four  hours.  For  household  use  the  apparatus  and  method 
of  Soxhlet,  Soltmann  and  Bertling  have  proved  the  best ;  if  these 
are  not  obtainable,  one  can  use  a  simple  enamelled  saucepan 
"  with  a  lid  which  co\ers  the  spout  "  (Biederl). 

Just  boiling  up,  as  is  usual  in  most  families,  is  by  no  means 
sufficient  to  destroy  germs.  Intense  heating  certainlv  has  disad- 
vantages for  the  milk,  as  the  curdling,  reducing  ihe  salt,  and 
changing  the  sugar  diminish  its  nourishing  qualities. 

The  so-called  Moeller-Barlow's  disease  has  been  traced  to  the 
use  during  many  months  of  overheated  milk.  Besides  which, 
raw  milk  contains  a  number  of  useful  ferments,  protective 
materials  and  immune  bodies  which  are  destroyed  by  the  great 
heat. 

On  account  of  the  last-named  reasons  v.  Behring  endeavoured 
to  make  the  consumption  of  pure  milk  possible  by  obtaining  milch 
cows  which  Avere  free  from  tubercle  bacilli  (prophylactic  bovine 
vaccination),  and,  besides  this,  to  sterilize  the  milk  and  render  it 
free  from  germs  by  means  of  a  low  temperature. 


I'XOI'IIM.AXIS  289 

V.  licliriiif^  rccoiiinifiHlcd  .'il  lirsl  ;iii  .-nldii  mn  <il  lorinalin  for 
(Ik-  i)i-cscr\;iJi(»ii  <>l  lli''  idiH.,  .'iH'l  K-iir hTiii^-  il  li.'innlcs.s  witli 
rcspccl  In  l)i)\'iiic  l);i(illi,  l;iirr  Sulniiin  ;iimI  ll'-piii  I"  iinprovf  (lif 
laslc;   bill    liillicrln   llicsc  ;illcin|)ls   li;i\c  l<'<l    I"   ii"   |)r.'i<  I  i' .'il   rcsiili. 

'I'o  ensure  oUl.'ii n i ml;  pnic  milk  from  he.-ililiy  ;iiifl  properly 
ivd  cows,  it  should  he  taken  onl\  I  rom  dependahle  model  dairies 
or  sh()|)s.  In  dairy  farms  where  hreedin^^  is  also  carried  on  we 
are  more  likclv  lo  meel  will)  animals  uhith  lia\f  been  injected 
with  tuherculin  than  in  mill<  d.'iiiies  only,  wliii  h  have  less  interest 
in  breeding. 

'The  same  caul  ion  must  be  exercised  wiih  respect  to  l)utter, 
cream,  curds  and  whey,  cheese,  k-ephir  and  yoL,Mirili,  in  which  'i 
is  well  known  the  bacilli  remain  \iruleni   lor  n.  lon<^-  lime. 

As  one  alone  amon^'  thousands  is  much  too  weak  to  protect 
himself,  and  as  an  individual  in  many  cases  does  not  understand 
the  question,  it  becomes  incumbent  on  the  State,  and  more 
especially  on  the  district  councils,  to  take  energetic  measures  on 
a  question  that  is  so  highly  important  for  the  weal  or  woe  oi 
the  population,  and  by  strict  superintendence  of  the  milk  put  on 
the  market,  as  well  as  by  undertaking  the  production  of  milk  for 
children  from  its  own  model  dairies,  to  be  able  to  sell  a  hygienic 
milk  free  from  all  suspicion  at  moderate  prices,  and  thus  to  supply 
the  poorest  children  with  that  food  which  is  necessary  for  their 
life  and  growth.  Only  in  this  way  can  the  terrible  evils  which  at 
present  exist  in  the  handling  of  milk  be  in  some  measure  re- 
dressed. A  whole  series  of  tasks  lie  before  the  councils,  which 
might  be  undertaken  in  conjunction  with  charitable  institutions ; 
the  foundation  and  support  of  a  bureau  for  advice  to  mothers, 
with  examination  of  the  mother  with  respect  to  her  ability  to 
suckle  her  child  (in  relation  to  tuberculosis) ;  feeding  institutions 
for  nourishing  the  mothers  during  the  period  of  lactation,  with 
offers  of  prizes;^  institutions  for  the  care  of  infants  and  children, - 
in  which  milk  would  be  given ;  milk  kitchens,  infants'  homes, 
fresh  air  homes,  and  children's  sanatoria.  These  institutions 
exert  a  favourable  influence,  not  only  on  the  mortality  of  children, 
but  their  bringing  up  in  general,  and  have  a  doubly  important 

^  Hohlfeld  found  that  the  offices  for  advice  for  mothers  were  only 
visited  after  prizes  for  suckling  had  been  offered,  and  only  mothers  seeking 
advice  were  eligible  for  the  prizes. 

■  It  is  quite  right  what  Comby  saA's,  that  the  care-stations  as  far  as 
they  reduce  the  danger  of  milk  infection  are  onh^  of  secondan,-  importance, 
especially  in  the  fight  against  tuberculosis,  but  thej'  are  of  great  importance 
in  the  avoidance  of  scrofulosis. 

19 


290  SCROFULOSIS 

effect  on  the  control  oi  l)()vin(.'  infection,  which  plays  a  consider- 
able part  in  scrofulosis  (see  Bibliography;  also  Latonr,  Comby, 
and  the  Minntes  of  the  XIV  Hygienic  Congress). 

( )n  ihe  State,  too,  devolves  the  more  difficult  task  which. 
unforiunatelv,  has  as  yet  only  reached  the  initial  stage,  of  com- 
bating and  exterminating  bovine  tuberculosis.  Propositions  have 
not  been  wanting  to  give  up  tlu'  breeding  of  cattle  entirely  in 
Europe  on  account  of  tuberculosis,  and  to  replace  it  by  the  breed- 
ing of  sheep,  goats,  and  horses  (Alendez).  But  no  uniformity  has 
been  arrived  at  as  to  the  best  means  of  attaining  this  end,  nor  have 
any  propositions  been  forthcoming  which  are  rational  antl  worth 
discussing. 

The  radical  measures  of  slaughtering  all  animals  that  react 
to  tuberculin  is  rendered  abortive,  according  to  experience  in 
Massachusetts  and  in  Belgium,  on  account  of  the  cost  and  the 
difticultv  of  obtaining  a  new  supply. 

The  onlv  thing  to  do  at  present  is  to  follow  Bang's  methods, 
viz.,  to  separate  those  animals  which  react  from  those  which  do 
not,  and  thus  to  obtain  bv  special  precautions  a  breed  of  calves 
free  from  tuberculosis  bv  means  of  sterilized  milk  free  from  bacilli 
and  to  kill  all  cattle  with  open  tuberculosis,  and  if  possible  those 
that  have  clinically  manifest  tuberculosis.  Denmark,  Sweden, 
Norwav,  Sec,  had  good  results  by  these  methods.  I  refer, 
amongst  others,  to  the  excellent  treatise  on  the  experience  gained 
in  Sweden.  In  Germany  there  are  many  supporters  of  the  less 
severe  methods  of  Ostertag,  according  to  which  one  endeavours, 
without  employing  the  tuberculin  with  older  animals,  in  the  first 
place  to  put  aside  at  first  those  proved  by  clinical  and  bacterio- 
logical examination  to  be  dangerously  tuberculous  with  open 
pulmonary  and  intestinal  tuberculosis,  &c.,  a  practicable  sugges- 
tion on  account  of  their  relatively  small  number.  Besides  this, 
an  attempt  has  been  made  to  obtain  a  breed  of  cattle  free  from 
tuberculosis  by  separating  all  calves  two  days  old  from  the  mother 
and  feeding  them  wiili  boiled  milk.  Here  and  there  success  was 
obtained  by  this  means. 

The  different  methods  of  protective  vaccination — namely,  the 
bovine  vaccination  of  v.  Behring;  the  injection  of  dried  human 
tubercle  bacilli  into  the  blood-stream  twice  at  intervals;  according 
to  Koch,  Schulz  (Xeufeld),  Wiesner,  Heymann's  method  of 
injecting  tauruman  ;  according  to  Klimmer,  the  injection  of  anli- 
phymatol — give  a  certain  protection  against  natural  infection;  but 
this  increased  power  of  resistance  does  not  appear  to  be  of  long 
duration  (Eber  and  Klimmer),  and  therefore  has  on  the  whole 
not  yet  led  to  an\-  practical  results. 


I'KOI'IIM.AXIS  291 

Milk  and  Food  Preparations. 

To  incrc.'isc  llic  niilrili\f  piopcri  ii-s  nl  mill-;  \\c  oIkti  have 
recourse  lo  .-iililici.-il  milk  prcpnr.-iiioiis,  wliii  h,  ,-ili  lioiic^li  ilicy  do 
not  offer  a  coinplclc  subslil  iilf  for  n;iiiir;il  mill-;,  arc  yet  iiiglily 
valuable  on  oeeasions  and  as  a  siipplcmcni.'iry  did. 

Natural  cream  mixlurcs  (.-iccordini;  lo  JJiederl,  fresh  cream, 
water,  milk,  sugar  and  milk-  in  six  ^i',-id.'ii  ions)  and  cream  con- 
serves increase  the  fatly  conicnls  (so  impoii,-iiii  toi-  digestion  and 
nourishment)  of  diluted  cows'  milk',  and  lender  goofl  sf-rxic*'  in 
protracted  disturbances  of  digestion,  in  ( nnsi  ii);ii  ion  (nftf-n  inlf-r- 
currenth'  with  diarrhcTca),  and  mucous  cnicrii  is.  I)iu  in  fat 
diarrlux^a,  on  the  contrar\',  sk'immcd  cows'  mill<  or  buiicrmilk'  is 
advisable. 

Of  such  artificial  preparations,  those  which  (liidlx-  come 
under  consideration  are  that  of  Biedert  von  Pizza,  prepared  in 
Zwingenberg,  containing  yi  per  cent,  caseine,  15'5  per  cent,  fat, 
46  per  cent,  sugar  ;  artificial  cream  mixture  (ramogen) ;  Lahmann's 
vegetable  milk;  Lolflund's  cream  conserve,  with  the  addition  of 
maltose;  Bolle's  keeping  cream;  Drenkhaus'  tinned  milk  (gaseine 
6  per  cent,  and  fat  16  per  cent.);  centrifugal  cream,  which  is  put 
on  the  market  fresh;  and  Steffen's  cream  mixture,  with  veal  broth 
prepared  from  it ;  Gartner's  fat  milk  (the  fattv  contents  are 
increased  by  centrifugalizing  diluted  milk);  vegetable  milk  of 
Hewel  and  Veitter  in  Cologne,  prepared  from  nuts  and  almonds 
(according  to  Klemperer,  containing  albumin  10  per  cent.,  fat  25 
per  cent.,  sugar  38'5  per  cent.,  salts  i'^  per  cent.). 

The  digestion  of  the  caseine  is  said  to  be  facilitated  bv 
Timpe's  milk  powder  (pancreatic  powder  and  sugar),  \'oltmer's 
artificial  milk  (a  cream  conserve  digested  with  pancreas).  Back- 
haus'  children's  milk  (obtained  from  rennet  ferment  and  trvpsin 
added  to  milk),  Rieht's  albumose  milk  (with  heated  albumin  of 
fowls'  eggs),  and  lastly  somatose  (cream  mixture,  with  addition 
of  this  albumose). 

On  the  whole  these  preparations  are  less  used  than  formerlv. 

As  preparations  rich  in  sugar  but  poor  in  fat  mav  be  men- 
tioned Liebig's  soup,  Keller's  malt  soup,  Allenburv's  infants' 
food,  Soxhlet's  nutritive  sugar,  buttermilk  (15  grammes  wheat- 
meal,  60  grammes  sugar,  11  grammes  buttermilk). 

As  an  addition,  to  make  the  caseine  more  digestible,  and  for 
a  short  time  as  a  change  from  milk,  the  following,  which  are  poor 
in  substance,  may  be  mentioned  :  the  glutinous  fluid  from  boiled 
oatmeal  or  barley,  gelatinous  solutions  (veal  bones,  s^um  arabic), 


292  SCROFULOSIS 

arruwrooi,  raccahoui,  salep,  lapioca,  and  especially  when  ihere  is 
a  tendency  to  diarrhoea,  white  of  egg  and  water,  bui  wiiere  there 
is  a  tenilency  to  constipation,  sugar  water. 

If  milk  does  not  agree  with  a  child,  even  when  diluted  (i  in 
lo),  for  example,  in  fat  diarrluva,  but  not  before  ihc  lenlh  week, 
recourse  must  be  had  to  disintegrated  flours,  the  carbi)hydrates 
of  which  are  already  dextrinized,  but  l)y  S(.)me  the  rapid  change 
of  flour  into  sugar  is  looked  upon  as  a  disad\anlage. 

Other  preparations  are  Ncstle's  children's  meal,  especially 
Kufeke's  children's  meal,  Liebe's  soluble  leguminose,  Rade- 
mann's  children's  meal,  and  Mellin's  food  for  infants,  Thein- 
hardt's  hvgiama  (very  good  with  cocoa),  Timpe's  strong 
semolina,  LiW'flund's  biscuit  meal,  Odda  (a  cocoa  and  milk  pre- 
paration), Muffler's  sterilized  infants'  food,  Riedel's  strength 
fo'od  (the  effective  components  of  barle\-  mall),  Pfund's  condensed 
m  ilk. 

Other  preparations  easily  digested  b\-  reason  of  the  fine  disin- 
tegration of  the  meal  are  :  — 

Knorr's  meals  (oatmeal,  rice,  flour,  or  tapioca);  Hartenstein's 
leguminous  meals,  maizena,  mondamin,  arrowToot,  and  lasth', 
the  cheaper  biscuits,  in  which,  by  the  double  healing  process  of 
baking  and  recasting,  the  starch  is  dextrinized  and  becomes  more 
soluble;  Friedrichsdorf,  ^^"urzen,  Opel's  biscuits.  These  pre- 
parations should  not  be  used  before  the  tenth  week. 

These  meals  can  be  used  as  gruel,  or  as  soup,  or  form  a  dish 
in  themselves,  and  may  serve  in  the  second  half-year  as  an  intro- 
duction to  solid  food.  This  transition  has  from  time  immemorial 
consisted  of  pap  from  ordinary  flour,  bread,  semolina  with  sugar 
and  milk,  -which  should  not  be  given  before  the  sixlh  month  to 
children  suspected  of  scrofulosis.  According  to  the  more  recent 
observations  of  Gregor  and  Czerny  the  early  and  regular  feeding 
^vith  preparations  of  meal  (wheat,  oats  and  maize)  as  an  addition 
to  milk,  instead  of  a  sugar  solution,  even  from  the  fourth  month, 
will  rather  diminish  than  increase  the  danger  of  scrofulosis. 

It  has  often  been  remarked  that  scrofulosis  mostly  develops 
some  time  after  weaning,  "when  the  child  begins  to  take  other 
food  than  milk,"  and  that  it  not  rarely  shows  itself  in  the  earliest 
years  in  those  children  who  have  been  brought  up  without 
mother's  or  nurse's  milk.  Early  and  plentiful  diet  of  amylaceous 
foods  has  long  been  considered  to  have  a  causative  connection 
with  scrofulosis,  but  more  recently  too  plentiful  feeding  with  minx- 
has  been  brought  forward. 

The  weaning  of  children,  which  may  usualU'  begin  at  about 
the  sixth  or  eighth  month,   is  preferably  postponed  with  children 


I'ROIMIVI.AXIS  293 

suspcclcd  ol  scioliildsis,  l)iii  alicr  six  inoiiilis  aiul  a  lialf,  inslf-ad 
ol'  mollici's  milk,  once  a  (lav  lliin  semolina,  sa^^n  or  v'x  c,  soiij)  of 
fresh  meal,  and  Ixmcs  wiilioiii  fal,  wiili  s<)U|)  lif-rbs  are  givf-n. 
The  same  ina\  \u-  L;ivcii  Id  (  liildrcii  WrDii^lii  up  on  cows'  milk. 
Aflei-  |)('rha|),s  diivc  or  four  wcfisS  a  second  milk'  nu-al  is  replaced, 
and  a  pap  of  one  or  I  wo  biscuits  or  loasled  bread,  or  semolina,  or 
groals  wilh  siipir,  milk  and  walcr,  is  |L,dven  in  ihe  usual  manner, 
or  one  nia\'  prcfci-  llic  pi  i\\  (ki-cd  meals  and  hnely  Iriluraled, 
leguminous  foods.  NOIk  of  egg  or  soft-boiled  eggs  are  also  gi\en. 
The  mother's  or  nurse's  or  cows'  milk  must  still  predominate. 
About  the  ninth  or  lenili  inondi  ilie  (  hild  must  be  completely 
weaned.     .See  Theodor's  "  Practical    Minis." 

As  an  additional  nourishment,  die  different  albuminous 
preparations  may  be  mentioned  : 

Milk  albumin  preparations  :  .Sanaiogen  (caseine,  with  5  per 
cent,  glycero-phosphate  of  sodium),  PlasuKjn,  Biosr)n,  Galac- 
togen,   Eulactol,   Albulaclin. 

Vegetable  albumin  preparations  :  T\obr)rat,  Xutrol,  Tutulin, 
Enterorose. 

Meat  albumin  preparations  :  Somatose,  Calodal,  Riba  (made 
from  fish,  especially  recommended  by  v.  Noorden). 

Preparations  from  combinations  of  albumin  :  Tropon  (from 
animal  and  vegetable  albumin),  Panopeplon  (beef  and  wheat), 
Visvit,  Biocitin,  Nutrin. 

Meat  preparations,  especially  A^alentine's  meat  juice,  \^"yeth's 
beef  juice.  Brand's  beef  essence,  Carvi's  meat  juice,  Denaever's 
meat  peptone,  Valid's  meat  preparation,  extract  of  meat  and 
peptone,  Liebig  (formerly  Kemmerische's  peptone),  meat  meal 
and  meat  cocoa,  Mosquera  (also  recommended  bv  ^loniin), 
Robur's  meat  juice,  &c. 

The  less  frequent  occurrence  of  tuberculosis  aniongst  flesh 
eaters,  as  compared  with  vegetarians,  induced  Richet  and 
Hericourt  and  others  to  recommend  diet  of  raw  meat  to  raise  the 
power  of  resistance.  The  results  appear  in  some  cases  verv 
favourable  (Monier,  Philip,  Josias  and  Roux,  and  Raissonier), 
but  in  others  no  success  was  observed.  In  anv  case,  the  use  of 
meat  freshly  compressed,  about  h  kilogram  of  meat  (Klein's  meat 
juice  pressed  fifteen  minutes)  or  finely  scraped  raw  beef,  in  small 
balls  (with  apple  or  apricot  jelly  for  weakly  persons),  is  to  be 
warmly  recommended  (see  Cornet,  "  Die  Tuberculose,"  second 
edition,  p.  937). 

In  the  second  and  following  years  foods  containing  starch 
meal,  which  easily  induce  intestinal  catarrh,  pulse,  cakes,  brown 
bread    and    fermentative    foods    must    be    given    as    sparselv    as 


294 


SCROFULOSIS 


possihlf.  and  niirogenoiis  animal  toocl,  milk  (i  liirc  daily),  is  ro 
he  preferred,  also  lightly  ht)iled  eggs  and  meat.  When  the  hack 
teeth  are  cut,  light  meats,  such  as  fowl,  pigeon,  veal,  calves'  hrains 
and  scraped  ham,  hoiled  till  lender,  minced  tlncly  ami  mixed  widi 
vegetahles  rubbed  ihrougli  a  sieve  and  of  iliin  i-onsisience,  may 
be  given. 

A  mixed  diet  is  the  best,  giving  special  attention  to  foods 
containing  mineral  salts,  siich  as  fresh  young  vegetables, 
especiallv  spinach,  and  niost  fruits;  such  vegetables,  rubbed 
through  a  sieve,  and  cooked  fruit  are  to  be  recommended  for 
children  suspected  of  scrofulosis  from  the  tenth  month  (Ritler 
and  others). 

In  the  third  year  the  children  can,  with  certain  restrictions, 
graduallv  take  their  place  at  table  with  their  parents,  provided 
the  food  is  prepared  under  hygienic  conditions  and  is  not  too 
highlv  spiced;  the  only  condiment  allowable  for  children  is  salt; 
at  the  same  time  milk  must  form  a  part  of  the  diet,  ^^  to  -J-  litre 
a  day;  it  is  sufficient  to  give  meat  once  a  day. 

Coflfee  and  tea  are  best  entirely  avoided  in  early  childhood, 
or  only  given  with  a  great  deal  of  milk  just  to  give  it  a  taste. 
Acorn  cotTee  ma\'  be  given  to  thin  children,  according  to  v. 
Ammon,  but  not  to  fat  children.  Alcohol,  which  was  formerly 
recommended  as  strengtliening,  is  now  generally  condemned,  and 
rightly  so;  it  is  now  only  ordered  for  children  as  a  medicine  in 
cases  of  acute  illness. 

As  further  nourishment  cod  liver  oil  and  malt  extract,  as 
mentioned  in  Therapeutics,  are  to  be  made  use  of  (see  p.  324). 

Older  children  must  be  accustomed  not  to  be  dainty.  Too 
great  indulgence  in  giving  way  to  fads  and  dislike  of  dishes  that 
are  the  most  appropriate,  frequently  from  the  example  of  parents, 
brings  its  own  punishment  often  for  the  whole  life.  Children 
refuse  at  a  critical  moment  food  upon  which  their  life  may  depend, 
with  "  I  can't,"  which  often  with  the  weakly  ones  prevents  any 
continued  and  decided  improvement  of  tlieir  state  of  nutrition. 
Of  course,  it  is  a  different  matter  when  dealing  with  real  idiosyn- 
crasies such  as  now  and  again  appear,  for  instance,  the  distaste 
for  milk,  butter,  &c. 

One  chief  condition  for  successful  development  is  strict  order 
and  punctuality  in  feeding.  At  first,  after  birth,  a  child  should 
take  nourishment  (at  36'5°  C.)  every  two  or  three  hours;  after  a 
few  months  every  three  hours,  with  the  exception  of  when  it  sleeps ; 
at  most,  six  or  seven  times  daily  altogether;  the  older  child  should 
not  take  more  than  fi\e  meals  at  stated  times  in  order  to  give  the 
digestive  organs  time  to  rest  between  meals.     As  a  feeding  bottle, 


I'ls( -I'llVLAXIS  295 

only  on*'  llial  is  c.-isib/  clc-iiicd,  is  snmolli  .-ni'l  li.'is  nn  india-ruhbf.r 
teat  is  allowable,  and  il  ninsi  Ix-  krpi  pum  1  iliousl y  <lcan  by  boil- 
in^-,  <S.c.;  an  cniplialic  warning'  iniisi  lu-  given  againsi  ihf;  bad 
liabil,  wliicli  is  as  dangerous  as  il  is  disgusting,  of  l)U)\ving  the 
food  or  chewing  il  beloreliand,  a  liahii  wlii*  li  has  claimed  many 
a  victim  (o  tuberculosis  and  scnilulosis  (sec  (ornet,  "  Die  'I  uber- 
culose,"  second  edition,  j).  24.^,). 

A  child  must  be  acciislnmed  lo  inaslicale  solid  food 
thoroughlv;  bv  eating  (piickly,  large  pieces  wliich  cannot  be 
penetrated  by  the  digestixc  lluids  are  easily  swallowed,  and  give 
rise  to  similar  evil  conditions  as  are  caused  by  excess  of  nourisli- 
ment  in  over-feeding. 

Not  only  the  necessar\-  and  allowable  (|uaniiiy  of  nourish- 
ment, but  also  its  suitable  nature  demands  our  whole  care  and 
superintendence.  The  instincts  of  the  child  can  be  allowed  to 
come  into  plav  only  so  far  as  is  consistent  with  convincing  our- 
selves of  its  thriving  by  regular  weighing. 

Experience  teaches  us  that  over-feeding  is  mr)re  to  be  feared 
than  under-feeding.  Ow'ing  to  the  narrow  limits  of  the  powers 
of  the  child's  stomach,  either  the  surplus  food  is  vomited  or — 
wdiich  is  less  harmful — it  passes  through  the  intestines  undigested 
and  unused;  but  under  certain  circumstances,  especially  in  con- 
tinued over-feeding,  undigested  remains  of  food  are  retained  in 
the  intestine,  irritate  the  mucous  membrane  by  the  processes  of 
decomposition,  lead  to  inflammation,  and  thus  diminish  the 
secretion  of  the  normal  intestinal  fluid  and  the  absorption  of  the 
chyme. 

Over-feeding  thus  becomes  under-feeding,  in  the  strict  sense 
of  the  word,  but  surpasses  the  latter  considerably  in  its  harmful 
consequences,  as  the  undigested  remains  of  food  in  the  intestines 
become  a  breeding  place  for  all  sorts  of  bacteria  and  a  source  of 
infection. 

Thus  over-feeding  has  an  important  significance  in  the  pro- 
duction of  scrofulosis.  The  bacterial  invasion  favours  to  some 
extent  the  inflamed  condition  of  the  intestinal  mucous  membrane, 
and  leads,  as  a  further  consequence,  to  the  swelling  of  the 
mesenteric  glands,  the  non-tubercular  form  of  tabes  mesenterica, 
and  may  also  favour  the  appearance  of  the  tuberculous  form, 
though  this  is  more  frequent  from  other  causes. 

The  more  indigestible  the  food,  which  is  given  in  too  great 
quantity,  the  greater  are  the  evils  it  induces.  In  this  particular 
the  caseine  of  cows'  milk  appears  considerably  to  surpass  that 
of  human  milk,  but  the  most  dangerous  is  undigested  starch 
flour;   perhaps   this   is   the   chief   cause   of   the   evil   odour   which 


296  SCROFULOSIS 

attaches  to  excessive  and  preniaiurL'  feeding  wiili  pap  eoniaining 
starcli  Hour,  especially  in  connection  with  sciH>tulosis. 

One  must,  therefore,  carefully  endeavour  to  avoid  (ner- 
feeding,  and  also  to  cure  as  speedily  as  possible  stomach  and 
intestinal  catarrh  and  other  affections  of  the  intestines  which  are 
accompanied  by  proliferation  of  bacteria,  it  goes  without  saying 
that  we  must  relieve  all  direct  under-feeding  quickly,  and 
deraneements  in  nourishment  causetl  b\-  faulty  construction  of 
the  mammary  glands  by  aphthous  inilammation,  by  thrush,  and 
cold  in  the  head  of  the  child,  which  make  sucking  difficult,  and 
in  case  of  necessity  see  that  sufficient  is  obtained  by  means  of 
the  spoon  or  feeding  boat,  or  in  many  cases  have  recourse  to 
stomach  tube  feeding,  as  Neiuiiann  and  Hochsinger  have  done 
in  cases  of  thrush  wilh  swelling  of  the  bronchial  glands. 

Faulty  Nutrition — Exudative  Diathesis. — The  experience  that 
many  children,  in  spile  of  apparently  aj^propriate  and  sufficient 
milk  food,  do  not  thrive  has  been  traced  in  the  last  two  decades 
principally  or  entirely  to  the  changes  in  milk  induced  by  bacteria, 
and  their  harmful  effect  on  the  mucous  membranes  of  the  stomach 
and  intestine.  It  is  only  in  the  last  decade  that  a  further  and  in 
many  cases  perhaps  a  more  important  reason  has  been  found  in 
the  unsuitabilitv  of  certain  of  the  component  parts  'of  milk. 
Biedert  considers  the  cause  to  be  especially  in  the  caseine  which 
is  over-abundant  and  more  indigestible  (faulty  nutrition  due  to 
albumin).  Czerny,  who  has  developed  the  theory  of  "  faulty 
nutrition  due  to  milk,"  lays  especial  stress  on  the  derangement 
of  the  changes  in  fatty  matter,  on  the  innate  incapability  of  some 
children  to  sufficiently  digest  the  fat  of  the  milk  wdiich  has  been 
introduced  in  large  quantities,  a  condition  which  he  considers  to  be 
the  expression  of  exudative  diathesis,  and  is  to  be  combated  by  a 
diminution  in  the  quantity  of  fat  given,  which  should  be  replaced 
by  food  richer  in  carbohydrates.  By  others  the  amount  of  sugar 
in  the  food  was  accused  of  the  disturbance  of  nourishment  (faulty 
nutrition  due  to  sugar,  Finkelstein  and  F.  L.  Meyer).  The  harm- 
ful bearing  of  the  salts  in  cows'  milk  in  the  nourishment  of  infants 
has  been  noted  (faulty  nutrition  due  to  salts) ;  infantile  eczema  has 
been  connected  with  it,  and  an  endeavour  has  been  made  to  relieve 
the  eczema  by  a  diet  poor  in  salt  (Finkelstein,  F.  L.  Meyer, 
Geisler,  Witzinger,  E.  Miiller,  and  others). 

In  opposition  to  these  stands  the  faulty  nutrition  due  to  flour, 
which  is  often  the  consequence  of  diet  for  infants  consisting 
principally  or  entirely  of  meal  (Langstein,  Salge,  and  others). 
With  this  diet  the  children,  who  look  blooming,  exhibit  remark- 
ably low  powers  of  resistance  against  infection  ;  later  they  become 


I'KOIMIYLyW'IS  297 

wcak'ci",  llioiii^li  llic\'  in;i\'  ((ivcy  lln'ir  hnilil',  (|c|c(i  (or  :\  liii)*' 
by  (I'dcm.'i.  'I'liis  coiidil  ion,  due  lo  I.-k  1;  ol  .-illjinnin,  v.ill  ])(• 
improved  and  cured  by  l('avin<^^  oil  die  iiic,-d,  and  repjarin^  it 
hy  human  or  eovvs'  milk,  Bicdcrl's  (ream  niixinrf,  Ciarlnf-r's  fat 
milk-,    Ijicdcrl's  cream  conserve,    U.-irkiians'   mill;,   \(  . 

In  die  lixclv  discussions  of  iIh'  last  icn  years  on  exudative 
diathesis,  which  is  staled  lo  l)e  thr-  prci cdin^'-  stage  of  scrofulosis, 
the  question  of  the  nutrition  of  s(  lofuloiis  (  hildrr-n,  and  chiidr'-n 
of  exudatixc  dialhcsis  who  haxc  a  irndrncv  to  it,  plays  a  \ery 
important  pa  it . 

C'ontrar\'  to  older  opinions,  wliicli  supposed  a  connection 
between  nourishment  and  the  lym])lialic  constitution,  in  the  last 
few  decades  very  abundant  nutrition,  especially  with  milk  and 
eggs,  has  been  considered  to  be  ap[)ropriale  tor  the  scrofulous, 
both  prophvlactically  and  therapeutically.  Czerny,  and  numerous 
physicians  who  niake  a  speciality  of  children's  diseases,  in  recent 
years  look  upon  it  as  a  releasing  agent  of  the  exudative  diathesis, 
and  base  their  theory  on  tiie  fact  that  exudative  symptoms  appear 
especially  just  at  the  time  of  a  great  increase  in  weiglit. 

As  before  mentioned,  it  is  the  derangement  in  the  metabolism 
of  the  fatty  materials  which  are  accused  by  Czerny  as  being  the 
releasing  agents.  On  the  supposition  that  the  limit  for  the 
assimilation  of  fat,  especially  that  in  animal  milk,  lies  particularly 
low,  it  is  required  that  fat  in  food  and  the  giving  of  milk  shall 
be  reduced  to  the  minimum  possible,  consistent  with  the  age  of 
the  child;  even  human  milk,  which  is  more  digestible  than  that 
of  animals,  appears  from  this  not  always  to  be  the  yery  best  diet, 
and  a  diminution  in  the  quantity,  and  a  partial  replacement  bv 
soup,  is  considered  necessary  under  certain  circumstances.  At 
the  same  time  eggs  are  to  be  excluded  from  the  diet  as  far  as 
possible,  being  strengthening  food  which  induces  oyer-nourish- 
ment,  especially  when  symptoms  of  exudatiye  tendency  are  already 
present.  The  loss  thus  sustained  is  to  be  made  good  by  intro- 
ducing carbohydrates,  but  without  falling  into  the  other  extreme 
of  their  too  abundant  introduction,  which  has  just  as  prejudicial 
and  dangerous  an  effect,  whilst  meat  diet  is  not  considered 
harmful. 

According  to  this,  in  the  first  two  years  of  life,  when  milk 
is  the  principal  article  of  food,  it  may  be  supplemented  by  carbo- 
hydrates, and  later  by  soup  and  yegetables.  With  infants  which 
do  not  thrive  with  ordinarily  appropriate  food,  or  Avhen  thev 
increase  excessively  in  weight  and  exhibit  symptoms  of  exudative 
tendency  (p.  54),  the  meals  at  the  breast  will  be  reduced  from  five 
to   four  sooner   than   with    normal   children,    even    at   the   fourth 


298  SCROFULOSIS 

momh,  ihe  time  for  feeding  reduced  from  iweniy  10  ten  minutes, 
and  the  mother's  milk  replaced  once  a  day  by  meat  soup  (made 
from  anv  meal),  with  meal  from  oats,  barley,  or  rice. 

According  to  Czerny,  after  the  second  year  vegetable  diet 
should  be  given  chieflv,  with  some  milk  {\  to  ^  litre),  nieat, 
uncooked  fruit,  but  no  eggs,  no  cream,  little  butter,  and  no  sugar. 

As  regards  the  success  of  this  mode  of  diet,  by  means  of  it 
manv  of  the  symptoms  which  have  been  noted  as  those  of  the 
exudative  diathesis  frequently  pass  off,  for  example,  paleness  (not 
caused  bv  auccmia),  catarrh  and  swelling  of  the  mucous  meni- 
branes,  lichen  urticatus,  &c.  Tlu'  scrofulous  habitus  with  pufi}' 
swollen  lips  is  often  favoiu'abh-  inlluenced,  though  this  occurs 
from  tuberculin  without  change  of  diet  (Heubner). 

Bin  manv  patients,  on  the  other  hand,  and  many  phenomena 
of  the  exudative  diathesis,  eczema,  &c.,  are  little  benefited  by 
this  treatment  (Pfaundler),  so  that  there  can  hardl\"  be  a  c|uestion 
of  "  conquering  the  diathesis  bv  dietarv  therapetitics,"  as  Czernv 
believes. 

If  it  were  proved  that  the  exudative  diathesis  depended  on 
disturbances  in  the  changes  of  fatty  matter,  the  principle  of 
removing  the  low  capabilitv  of  performing  this  work  before  it 
had  begun  to  manifest  itself,  and  bv  great  care  to  change  it  to 
physiological  activity,  would  without  doubt  be  justified. 

It  is  just  as  little  proved  that  this  mode  of  dieting  is  the 
cause  of  the  temporary  favourable  effect,  for  it  is  questionable 
whether  this  eft'ect  is  to  be  ascribed  to  the  reduced  amount  of  fat 
given,  or  the  removal  of  the  harmfulness  due  to  fatty  nutrition, 
or  if  it  be  not  the  simple  consequence  of  the  cessation  of  over- 
feeding. 

Wgetable  food  with  spare  diet  has  long  been  recommended 
by  the  French  for  arthritis  in  children,  and  the  earh-  giving  of 
vegetables,  which  lias  been  especially  recommended  by  Ritter 
for  years,  is  appropriate  in  the  exudative  diathesis,  but  principally 
on  account  of  avoiding  over-feeding  (Stein itz). 

But  nevertheless  Czerny's  method  in  the  prophylaxis  of 
simple  pyogenic  scrofulosis  and  its  precursors,  especially  in  puffy, 
fat  children,  will  be  kept  in  view  and  will  often  be  used  with 
advantage. 

The  modern  device,  "  no  over-feeding,"  is  certainly  justi- 
fiable for  those  many  mothers  who  stufif  their  children,  without 
knowing  when  to  stop,  as  if  they  had  a  goose  to  feed  for  the 
table,  or  a  calf  to  fatten  for  slaughter.  So  far  the  general  opposi- 
tion to  over-feeding,  to  the  heaping  up  of  puffy  spongy  tissue, 
which  is  defenceless  against  every  infection,  is  well  grounded. 


n'<  )i'iisi,AX[,s  299 

IJiil  iIh-  iIm'oi)  [)r(»|)oiiii(|i-(|  l)\  (zciiiv  III  only  ^i\in^  llu; 
smallcsl  (|iianlilv  of  cow's  milk-  or  tood  wliit  li  is  jiisl  f-nou^li 
Lo  procure  "  siiHicicnl  iiu  rc.'isc  oi  wciglit  to  satisfy  moderate 
demands  and  lo  cnsinc  l;oo<I  hodily  develo|)menl  "  is  too  one- 
sided, unless  one  lias  to  ((iinbai  direalened  over-noiirislimeni  with 
its  (:()nse(|uenc.es,  for  a  (ciiaiii  excess  of  foo(i  and  a  moderate 
puttin<4'  on  of  fat  is  fre(|nenil\    not  withoitt  \aliie  at  a  later  time. 

Brehmer  was  nol  wron^  wlieii  lie  foimed  a  worse  proj^nosis 
for  the  (tiberciiloiis  who  from  dieir  \oiiih  had  had  poor  appet  lies 
tlian  for  those  who  wcie  a(  (  nslonied  lo  eat  well. 

When  we  are  dealine  wjdi  inherculo-scrofulosis,  with  a 
manifest  infection  of  the  body — I  am  anticipating  the  next  chapter 
— 1  consider  it  a  direct  error  to  be  so  anxious  to  avoid  putting  on 
more  weight,  as  the  future  of  (he  lubercidous  aduli  often  depends 
upon  whether  we  can  at  the  proper  lime  successfullx'  combat  the 
threatening  fahing  away  of  the  body  by  plentiful  nourisiiment, 
even  bv  a  certain  amount  of  feeding,  of  course  kept  within 
bounds,  as  in  this  case  loss  of  weight,  from  whatever  cause  it 
may  arise,  is,  as  a  rule,  connected  with  an  aggravation  of  the 
disease  with  a  spread  of  the  process,  and  often  introduces  the 
beginning  of  the  end;  therefore  it  appears  to  me  that  scrofuio- 
tuberculous  children  in  a  good  state  of  nutrition  have  more 
prospect  of  cure  than  those  moderately  nourished,  who  have  been 
only  accustomed  to  eat  what  is  absolutely  necessarv.  Recent! v 
Calot,  as  the  result  of  years  of  observation,  has  recommended 
over-nutrition  in  coxitis. 

HARDENING. 

To  protect  the  little  ones  from  a  tendencv  to  cold  and  catarrh 
of  the  mucous  membranes,  which  often  become  the  point  of  entrv 
for  bacteria  and  may  become  the  starting-point  for  scrofulous 
symptoms,  they  must  be  subjected  to  rational  hardening,  which 
increases  the  functional  efficiency  of  the  skin  and  prevents  too 
great  stagnation  of  warmth  internally. 

One  must  begin  at  2  or  3  years  of  age.  The  child  must  be 
sponged  down  with  cool  water,  from  30°  to  20°  C.  temperature,  in 
a  warm  room  (for  the  method,  see  Cornet,  "  Die  Tuberculose," 
second  edition,  p.  958),  to  be  followed  either  by  exercise  or  resting 
a  quarter  of  an  hour  in  a  warm  bed,  and  other  necessarv  baths 
may  be  reduced  to  i  to  2  in  a  week.  As  this  sponging  is  to 
be  preceded  by  a  storing  up  of  heat  on  the  surface  of  the  bodv. 
the  child  should  be  taken  from  the  bed  to  be  sponged  down,  or 
it  should  be  given  after  first  subjecting  it  to  drv  rubbino-.     With 


300  SCROFULOSIS 

verv  weaklv  cliiklren  a  pari  may  be  rublied  al  a  linu'.  or  ihey 
should  be  rubbed  with  diluted  brandy. 

Vevv  frequently  every  sort  ui  procedure  thai  sirikfs  aAd  ov 
thai  draws  heat  from  the  body  disagrees  decidedl\  wiih  so-called 
lymphatic  children  and  especially  fat  children  ;  they  get  headache, 
giddiness,  &c."  In  sucli  cases  we  must  not  try  to  accustom  them, 
but  let  them  have  warm  mint-ral  hailis  instead  of  cold  sponging 
(see  p.  328),  \\liich  ahnost  always  are  followed  by  good  results. 

The  living  rt)onis  of  the  child  must  be  moderately  warm, 
not  over-healed,  the  bedroom  kept  al  a  temperature  noi  imder 
(8°  to)  10°  C,  the  clothing  must  be  suitable  to  the  lime  of  year. 
The  spoiling  of  children  by  over-anxious  mothers  b}  too  \yarm 
clothing,  thick  comforters,  scarves,  &c.,  is  as  bad  as  just  the 
opposite  habit  of  letting  the  children  run  about  with  naked  arms 
and  legs  in  cold  weather.  Owing  to  the  great  sensili\eness  of 
the  skin  in  these  children,  irritation  by  coarse  woollen  clothing 
must  be  avoided, 

CAUTION   DURING  ILLNESS  IN  THE  FAMILY. 

Should  there  be  a  tuberculous  person  in  the  fami!}',  with 
open  tuberculosis,  either  the  j^alient  or  the  child  should  be  remo\-ed 
as  soon  as  possible.  This  is  naturally  all  the  more  necessary  the 
smaller  and  poorer  the  dwelling  conditions  are.  Tiiere  is  in 
France  a  Society,  called  "  CEuvre  de  preservation  de  renfant," 
whose  object  it  is  to  take  the  children  of  tuberculous  parents  from 
their  endangering  environment  and  to  place  them  with  suitable 
persons  in  the  country  at  a  cost  corresponding  to  their  position 
in  life. 

\\"ith  such  care  f(jr  the  children  a  certain  pressure  on  the 
parents  is  justihed  (see  Neudecker's  statements  at  the  Vienna 
Conference  on  Tuberculosis,  1907).  The  Americans  are  much 
more  energetic  in  carrying  out  measures  w^hich  they  consider 
necessary.  For  example,  in  Philadelphia  some  parents  who 
refused  to  allow  their  children  to  be  treated  for  an  affection  of  the 
eyes  in  the  way  proposed  by  the  school  doctor  were  summoned 
for  neglect  of  their  children  (Ensch). 

If  the  removal  of  the  child  is  not  possible  it  should  be  kept 
as  far  as  may  be  from  the  patient. 

In  any  case  in  the  family  of  a  tuberculous  patient  the  greatest 
care  should  be  exercised  in  removing  the  secretion  in  the  most 
hygienic  manner.  The  patient  must  expectorate  the  sputum  into 
a  vessel  or  a  spitting  cup  which  contains  water,  to  prevent  its 
drying,    this   must  be  prevented   from    falling  and   be   constantly 


I'KfJlMIYLAXIS  3^^' 

(Mupliccl  ;  when  couf^liini;  li''  niusi  liold  .-i  liaiidkcrcliici  b'.-forf,-  his 
mouth,  as  I  nxoniincndcd  in  iSSS,  !<.i)_^  hrfore  "  Flugge's  droplet 
infection"  was  ini  rodiiccd  (lor  Inllcr  ddails,  sf(*  G.  Cornet, 
"Die  Tubercuiosc,"  second  (uhlion,  pp.  H^yj-H^o).  Otlier  neces- 
sary measures  in  hilxTculosis  (vvhi(  h  I  lia\e  lidly  entered  into 
elsewhere),  snch  .-is  <  IcanHness  in  die  room,  on  \\\(t  landinj,^  and 
stairs,  in  schools,  placing'-  si)illoiins  .-iltnui,  si-iac  to  keep  scrofulous 
infection  from  (lie  child. 

VUv.  same  precaution  is  nece.s.sary  for  patients  wilii  every  sort 
of  catarrh,  because  Iheir  .secretions  fj'-cnerally  contain  pus  cocci. 

Successful  prophylaxis  in  this  direction  nece.s.sarily  pre- 
supposes that  the  tuberculous  patient  and  those  about  him  are  not 
deceived  iis  to  llie  nature  of  his  disease  by  euphemi.stic  terms,  but 
are  informed  that  danger  of  infection  is  present  and  how  it  is  to  be 
avoided. 

The  intention  of  sj)aring-  the  feelings  of  the  patient  by  sup- 
pressing the  diagnosis,  .so  as  not  to  exxite  him,  is  a  crime  against 
those  about  him  which  cannot  be  sufiiciently  condemned. 

For  more  than  twentv-tive  years,  amongst  my  numerous 
phthisical  patients,  I  have  followed  the  principle  of  informing 
them  in  a  considerate,  tactful  way  of  the  diagnosis,  naturally 
emphasizing  the  prospect  of  recovery,  and  I  have  never  had  any 
harm  result  to  the  patient,  and  only  benefit  to  those  abr)ut  him. 

If  a  member  of  the  family  suffer  from  other  suppurations  or 
open  scrofulous  foci  and  fistuUe,  a  dry  or  damp  dispersal  of  the 
secretions  containing  bacteria  is  prevented  ]:)y  covering  the  wound 
or  fistula;  the  covering  must  be  changed  when  children  are  absent, 
taken  away  at  once  and  destroyed,  together  with  anv  soiled  pieces 
of  bandage  (for  disinfection  of  linen,  see  p.  282). 

The  danger  of  transmission  by  tuberculides  is,  perhaps,  not 
quite  excluded,  but  hardly  plays  a  part  worth  mentioning  on 
account  of  their  being  seldom  caused  by  virulent  bacilli. 

Kissing,  especially  on  the  mouth,  is  to  be  avoided,  not  onlv 
by  near  relations,  but  also  by  acquaintances,  more  especially  bv 
those  affected  with  catarrh  or  tuberculosis.  Children  must  be 
taught  impressively  never  to  allow  themselves  to  be  kissed  by 
strangers. 

These  precautions  are  not  only  for  parents  and  brothers  and 
sisters,  but  for  all  persons  who  come  in  contact  with  the  child. 
We  trouble  ourselyes  far  too  little  about  the  state  of  health  of 
our  nurses  and  servants,  their  sense  of  cleanliness,  or  their  bad 
habits,  and  then  wonder  when  scrofulosis  or  tuberculosis  is  found 
in  the  family — "dropped  from  the  clouds,"  as  the  saying  is — 
which  then  spreads  further. 


302  SCROFULOSIS 

Sometimes  a  chikl  has  iiilierrulous  olands  although  the 
greatest  care  has  l)een  exercised  with  him.  ahhough  the  whole 
family  and  servants  are  healthy  and  infection  by  milk  is  as  good 
as  excluded,  so  that  one  is  inclined  to  despair  of  ihc  tise  of  all 
precaiiiitins.  ()n  cIosit  in(|iiii"\-  among  ihc  circle  ot  acc|uain- 
tances  in^t^  disi-oxcrs  thai  ai  ilic  house  of  the  grandmother,  or 
some  other  relation  or  friend,  whom  llic  child  oficn  \isils,  either 
one  of  these  persons  was  lulicrculmis,  or  one  of  (he  siMwanls  who 
had  t)ccupied  herself  wiih  ihe  child. 

In  a  case  of  uibcrculo-scrofulosis  which  was  at  lirsi  diffu-ull 
to  explain,  I  was  onc-e  able  to  demonstrate  thai  the  ajDparently 
iiealthv  housemaid  of  the  aunt  was  doubtless  the  source  of  infec- 
tion ;  she  was  luberculous,  and  when  fetching  and  bringing 
back  the  child,  whic-h  later  l^ecame  luberculous,  liatl  kissed  and 
hugged  it. 

Rational  ]Droph\laxis,  therefore,  must  notice  such  appar(Milly 
remote  points  and  must  walch  over  and  embrace  the  super\ision 
of  the  whole  circle  with  whom  liie  child  comes  into  contact.  A 
custom  usual  among  the  poorer  classes  of  utilizing  the  clothes 
of  adults,  or  clothes  which  have  been  given  to  them  for  the 
children,  is  a  source  of  many  dangers  unless  the}-  have  first  been 
disinfected,  which  should  be  done  free  of  cost  ! 

Increased  caution  is  demanded  for  the  child  at  home  and 
amongst  one's  friends  shortly  after  recovery  from  measles,  scarlet 
fever,  or  whooping-cough,  as  after  these  illnesses  the  mucous 
membranes  appear  to  be  especially  sensitive  and  capable  of  infec- 
tion. At  this  time  change  of  air,  with  the  opportunity  of  being 
much  in  the  open  air,  is  especially  urgent.  Fears  which  were 
formerly  connected  with  vaccination  have  lost  their  meaning 
since  the  method  of  vaccination  from  arm  to  arm  has  been  given 
up,  and  animal  l}mp]i  is  generally  used,  but  the  Aaccination 
wound  requires  thorough  protection  from  dirt. 

DIFFICULTIES  OF    PROPHYLAXIS. 

The  special  meastires  given  ab()^•e  for  the  projolulaxis  of 
scrofulosis  are,  on  the  whole,  not  new.  If  I  except  the  measures 
for  avoiding  infection  which  have  been  more  exactly  laid  down 
within  the  last  twenty  years,  and  which,  as  I  believe,  are  based 
in  the  greater  part  on  my  experiments  on  animals  (see  p.  79) 
and  the  better  knowledge  of  the  paths  of  infection  due  to  them, 
they  have  been  recommended  emphatically  in  very  little  altered 
form  by  older  authors  at  liie  end  of  the  centur\-  before  last,  and 
at  the  beginning  of  last  century  by  White,  Ilufeland,  and  Lebert, 
but  the  success  was,  on  the  whole,  as  far  as  can  be  judged  without 


I'KOI'IIYI.AXIS  3^3 

trustwoiiliy  l"ij^nir<'S,  (|iiilc  iiu  ompl'i'-  'ind  imsalislaclory,  for 
scrofulosis  hardly  play^'d  a  1<-s.s<t  |.,hi  in  |).ii  hology  (at  least  lill 
a  few  years  a^nt)  lliaii  Inrmcrly. 

'Idu'  reason  lor  iIm-  nnsal  islat  lory  resnlis  lies  partly  in  llie 
(iisrcf^ard  of  the  <  ipp^rl  unit  ies  of  infection  and  the  non-avf)i(Jancc 
,,|'  (hem,  hnl  no  less  in  the  diflii nil ies  and  (hreri  impediments 
which  the  carrying  out  of  the  phophylaxis  described  lias  met  with 
in  many  respects  througli  the  great   increase  of  the  population. 

Instruction. 

'i'he  proph\laNis  lavs  such  heavy  tasks  on  the  nutrition,  care 
and  bringing  up  of  children,  that  the  proper  rarrying  out  of  it 
presupposes  a  high  sense  of  (lui\-,  dcNoiion  and  self-sacrifice,  and 
last,  l)Ut  not  least,  a  proper  understanding  on  the  part  of  those 
entrusted  with  tiie  care  of  the  children.  I'.ven  with  mothers  who 
are  willing  to  devote  themselves  to  their  natural  duty — the  care 
of  the  child — these  qualities  are  not  always  combined.  In  con- 
se(|uence  of  the  false  modern  education,  without  knowledge  of 
household  matters,  the  necessary  measure  of  understanding  is 
wanting  in  the  young  mother,  when  the  new  task  of  careful 
attention  to  children  lies  before  her,  though  she  have  all  the  love 
and  devotion.  She  is  forced  to  hand  over  the  care  of  her  child 
to  hired  strangers  as  an  inevitable  resourse.  These,  too,  even 
with  goodwill,  lack  the  necessary  training  and  bring  with  them 
only  the  barest  knowledge  or  old-fashioned  wrong  opinions. 
Just  as  it  is  required  of  male  adults  that  they  shall  attend  con- 
tinuation classes,  so  should  it  be  required  of  female  adults,  in  the 
interests  of  their  general  culture,  that  they  should  attend  a  course 
of  housekeeping. 

We  must  continually,  by  word  and  picture,  by  effective 
placards  and  by  disseminating  notices,  work  and  instruct  others 
in  the  avoidance  of  diseases,  especially  of  tuberculosis  and  scrofu- 
losis, and  in  the  rational  care  of  children  in  all  places  where  the 
mother  can  be  influenced,  in  information  bureaux  and  places  for 
the  care  of  adults  and  children,  in  maternity  homes,  in  kitchens 
for  nursing  mothers,  in  milk  kitchens,  in  short,  in  every  charitable 
institution,  by  midwives,  vaccination  officials  and  sick  nurses 
when  they  are  called  to  families. 

For  older  children  there  should  be  posted  up  in  the  school- 
room, and  in  other  suitable  places,  pithv  rhvmes,  such  as  the 
following  :  — 

"  \\^ash  your  hands  before  you  eat. 

Clean  your  nails,  then  take  vour  seat." 

These  are  small  weapons  in  the  fight,  but  here  and  there 
the  sup'gestions  mav  fall  on  o-ood  soil  and  bear  fruit. 


304  SCROFULOSIS 

Dwelling-houses. 

Besides  want  of  propcT  understanding,  wliirh  anidngst  the 
better  classes  is  ilu-  principal  drag  on  prophylaxis,  other  causes, 
which  comprise  by  lar  the  greater  part  of  the  cases,  namely, 
outward  bad  .conditions,  are  in  themselves  opposed  to  rational 
measures.  Want  forces  the  mother  to  assist  in  earning  the  living, 
and  as  long  as  she  is  away  at  work  the  child  is  left  to  itself.  The 
condition  of  the  dwellings  makes  a  mock  of  ilic  most  modest 
demands,  and  even  cleanliness  and  the  use  of  water  are  kept 
within  the  narrowest  limits  for  the  sake  of  economy. 

()ur  in\ csiigations  in  lubrrculosis  ha\e  only  too  otlcn  led 
us  into  houses  or  dark  dwellings  up  a  court,  where  parents  and 
five  children  have  shared  two  or  three  beds  (see  also  my  "  Die 
Tuberculose,"  second  edition,  pj).  409  and  885;  also  Marcuse  and 
■  Kohler).  In  Prussia  in  1896,  342,612  children  up  to  the  age  of 
13  died,  amongst  whom  116,217  died  from  diseases  (excepting 
disorders  of  nuirilion)  for  which  insufficient  or  too  confined  living 
conditions  must  be  made  answerable  in  a  very  great  measure, 
either  directlv  or  indirectlv,  by  being  favourable  to  contagion  : 
deaths,  that  is,  from  tuberculosis,  scrofulosis,  measles,  scarlet 
fever,  whooping-cough,  &c. 

The  great  influence  poor  li\ing  conditions  exert  on  the  pro- 
duction of  scrofulosis  is  certain,  and  radical  redress  can  only  be 
expected  from  a  law  respecting  dwellings  which  takes  hygiene 
in  some  measure  into  account.  But  as  carrying  it  out  would  dive 
deeph'  into  the  pocket,  it  can  only  be  done  slowly  and  by  degrees, 
and  with  all  possible  forbearance.  Hitherto  the  governing  and 
law-authorities  have  carefully  avoided  the  matter;  but  even  should 
such  a  law  l)e  passed,  years  must  elapse  before  any  striking  result 
can  follow. 

Are  we  to  sit  down  quiell}-  till  then  and  look  on  while 
scrofulosis  decimates  our  children  and,  which  is  worse,  creates 
lifelong  cripples  and  sufferers  unable  to  earn  their  own  living? 
Let  us,  till  a  statutory  improvement  of  unhygienic  dwellings  takes 
place,  at  least  endeavour  to  remove  those  children  who  are  most 
exposed  to  danger  from  the  worst  dwellings  and  so  reduce  the  evil. 

INSTITUTIONS  FOR  THE  CARE   OF  CHILDREN. 

We  would  formulate  our  demands  thus  :  in  all  districts 
suf^cient  arrangements  shall  be  made  to  allow  of  there  being 
placed  during  the  day  in  a  healthy  environment  all  those  children 
who,  in  consequence  of  bad  conditions  of  dwellings  and  of 
poverty,  are  exposed  in  a  considerable  degree  to  the  danger  of 


I'KOI'IIYI.AXIS  3^5 

arreslcd  (I('vcI(.|'ii)<miI,  (.1  Inlliii,^  \i<iiiii,s  lo  i  ul,.i<  iilosis  nr  srn.fu- 
losis,  or  <)lli«'|-  siicli  <li.scasc.s  \vlii(  li  cxpcrimrr-  lias  laiiglii  ns  ,'.i<- 
C()nse(|UcnL  upon  sucli  inipro|)<M-  < ondii  inns. 

The  above  fi^nircs  pi-ov<-,  l)y  iImmt  M-mMr.  magniiudr-,  tlic 
l)r('s.sing  necessitv  of  our  demands,  noi  only  lo  recommend  much 
air  and  good  nourishnieni,  1)ul  also  lo  j^rorurc  ihe  means  V>y  which 
a  larger  number  of  |)oor  children  will  be  able  lo  enjoy  lliese 
adxanlages. 

iMrsl   we  ninsl  deal   wiHi  cliildrcn   under  school  age,   ijicn   with 

school  (-hildren. 

Im)1-  the  former  ihere  are  creches,  eslablislunents  for  taking 
charge  of  children,  kindergartens,  and  foresl  recreation  grounds. 

Creches,  which  have  existed  for  years,  may  answer  our 
purpose  of  taking  children  out  of  their  dangerous  surroundings, 
even  if  onlv  within  very  modest  bounds.  They  are  intended  for 
infants  and  children  up  to  one  year,  and  were  first  instituted,  as 
far  as  I  know,  by  Marbeau,  somewhere  about  the  forties  of  the 
nineteenth  century,  in  Paris.  Establishments  for  taking  care  of 
voung  children  from  the  ages  of  2  to  6  were  instituted  earlier,  at 
the  end  of  the  eighteenth  century,  by  Oberlin  in  Alsace,  and  in 
Scotland  by  Owen.  They  are  intended  especially  for  children 
whose  parents,  being  at  work  all  day,  cannot  give  them  the 
necessary  attention  ;  they  have  since  had  imitators  in  all  countries. 

The  children  stay  in  these  institutions  from  7  a.m.  till  4  or 
6  p.m.,  are  waited  on  by  a  trained  kindergarten  teacher,  and  are 
amused  with  games,  go  home  at  midday,  or  are  fed  in  the 
institution  at  a  cheap  rate  (10  to  20  pfennig).  When  there  is  a 
garden,  and  the  weather  and  the  teacher  allow  it,  they  spend 
most  of  their  time  in  the  open  air.  The  parents  pay  different 
prices,  from  half  a  mark  to  4J  marks  per  month,  and  frequently 
nothing  is  demanded. 

These  institutions,  which,  when  first  started,  only  took  school 
and  sofne  social  considerations  into  account,  need  reform 
hygienically,  where  possible  they  should  be  removed  outside  the 
town  and  increased  to  a  sufficient  number;  then  they  might  be  of 
importance  for  public  hygiene,  and  a  support  in  the  battle  against 
the  high  mortality  amongst  children. 

In  my  former  edition  on  scrofulosis  I  gave  the  supreme  role 
in  the  fight  against  scrofulosis  especially  to  kindergartens,  but 
I  must  confess  these  institutions  have  been  outstripped ;  a  far 
more  important  plan,  the  most  useful  weapons  in  the  fight  are 
the  forest  recreation  places,  instituted  bv  "Wolf  Becher  and 
Lennhoff,  which  enable  a  number  of  children  to  enjov  a  sojourn 
in  good  air  for  a  small  outlay. 

Ritter's  attempt   may   be  considered   as   the   pioneer   of   the 
20 


306  SCROFULOSIS 

toresi  recreation  places.  In  1893  he  look  scrofulous  children 
living  in  Berlin  from  their  unhealthy  houses,  and  gave  ihem  a 
place  during  the  day  free  from  dust  and  amongst  trees,  made  them 
do  calisthenic  exercises,  had  them  massaged,  and  provided  good 
nourishing  food. 

Unfortunately,  after  a  few  years  the  inslitutit)n  was  given  up 
for  lack  of  means  to  carry  it  on. 

Wolf  Becher  and  Lennhoff  first  brought  their  idea  of  found- 
ing forest  recreation  places  before  the  Congress  on  Tuberculosis 
in  BerHn  in  1899.  For  this  purpose  a  piece  of  Government  or 
common  forest  in  the  neighbourhood  of  the  town  should  be  given 
free  of  cost,  to  be  used  as  a  place  of  recovery  for  the  sick  and 
convalescent,  a  place  of  shelter  being  provided  also  for  rainy 
weather  by  constructing  a  Docker  shed,  and  a  simple  kitchen 
should  be  arranged  for. 

With  the  help  of  the  Red  Cross  the  first  forest  recreation 
place  was  established  in  1900  on  the  Jungfernheide,  near  Berlin  ; 
later  others  were  started  in  Leipzig,  Frankfort-on-Main,  Hanover, 
&c.  These  forest  recreation  places,  which  were  first  intended  as 
day  sanatoria,  differ  from  all  other  similar  institutions  by  their 
much  simpler  arrangements,  by  having  their  land  free,  their  low 
cost  on  first  building,  and  the  way  they  are  carried  on,  which 
renders  it  possible  to  give  a  hygienic  place  to  stay  in  for  the  day, 
answering  all  purposes  w"ith  very  little  expense.  At  first  intended 
for  adults,  the  good  results  attained  induced  similar  recreation 
places  to  be  erected  for  weakly  children  (in  Charlottenburg),  and 
for  infants  (by  the  Women's  National  Union  in  Pankow).  In 
the  infants'  recreation  places  the  little  children  may  often  remain 
all  night  (the  charge  being  i  mark  for  day  and  night),  whilst  the 
mothers  go  home  at  night. 

Such  recreation'  places  must  naturally  be  easily  reached  from 
the  town.  A  piece  of  forest  from  3  to  4  morgen^  is  generallv 
sufticient;  the  land  must  be  dry  and  permeable,  be  slightly  on  the 
slope,  and  w'holesome  fresh  water  must  be  in  the  neighbourhood. 
I  cannot  here  go  into  details. 

Soon  stronger  sheds  in  special  material  and  reinforced  con- 
crete replaced  the  Docker  sheds;  sometimes  heating  arrangements 
were  added. 

Often  the  children  are  fed  entirely  and  milk  is  given ;  of 
course,  with  the  small  means  at  command  the  food  is  simple,  but 
it  is  suf^cient  and  nourishing.  Oatmeal  with  milk,  oat  cocoa, 
rye  broth,  milk  and  bread,  and  at  midday  meat,  vegetables,  &c. 

In  Berlin  the  whole  cost  of  feeding  the  children  comes  to 
about  50  pfennig  (6d.)  per  day  per  head. 

'  Roughly    li    to   2   acres. — Translator. 


I'KOI'IIYLAXIS  307 

III  many  cases  llic  n-crcal  ion  plat  cs  (ould  he  combined  with 
workmen's  kilclicns  lo  icdncc  \\\c  cost  and  Um-  number  of  persons 
em|)l()yed.  The  cost  ol  loresi  recreation  places  is  not  lo  bf 
compared  vvilli  those  ol  consnmi)!  ion  sanalori;i,  where  one  bed 
comes  lo  about  5,000  (/,25o)  to  (),ooo  (/J,r-,()<>)  marks,  whilsl  thr: 
building-  of  an  entire  forest  recre.-il  ion  pl.-icc  (osis  i(;,ofjo  ('/..yx;) 
to  12,000  (^600)  marks  if  Ihere  is  no  oiiiw.ird  show,  and  only 
Lisefid  and  necessary  re(|iiircmenls  ,'ire  kcpi  in  view,  so  that  the 
cost  for  one  year  for  two  or  lour  cousunipi  i\  e  patients  would  in  a 
forest  home  benefit  over  100  persons. 

Insurance  offices  and  district  councils  have  here  and  ihere 
o-ranted  loans  without  interest  to  enable  these  institutions  lo  b«- 
erected,  and  the  central  committee  for  combat in^^  tuberculosis  has 
often  given  subscriptions  for  the  purpose. 

It  is  the  children  in  such  institutions  who  repay  us  most. 
To  live  in  narrow  courts  and  streets  is  most  dangerous  for  the 
development  of  their  bodies,  and  stamps  them  for  their  whole 
life  with  the  seal  of  inferiority,  while  Hfe  in  the  woods  revives 
and  strengthens  them  bodily  and  mentally. 

The  day's  programme  is  about  the  following:  Immediately 
on  their  arrival  the  children  have  their  breakfast,  then  under  the 
superintendence  of  the  kindergarten  teacher  they  do  easy  gym- 
nastic exercises ;  next  tliey  are  occupied  with  school  work, 
instruction  and  play,  which  is  interrupted  for  a  short  time  for  a 
light  lunch.  After  the  midday  meal  they  have  to  rest  awhile; 
in  the  afternoon  simple  games,  wallvs,  collecting  flowers  and 
insects,  and  tea ;  after  a  light  supper  they  start  home. 

The  infinite  hygienic  utility  of  tliese  forest  recreation  places 
needs  no  further  justification  ;  they  enable  the  children  to  spend 
the  day  in  the  fresh  forest  air  and  bright  sunshine  instead  of  in 
small,  close,  darlv  houses,  and  instead  of  insufficient,  inappropriate 
food,  they  get  good,  plentiful,  wholesome  food  with  vegetables 
and  milk.  The  increase  in  w^eight  of  the  children,  their  improved 
and  sometimes  blooming  appearance  after  a  short  time,  speak 
much  more  plainly  for  it  than  long  expositions. 

To-da}^  we  may  truly  say  it  is  a  disgrace  for  a  medium-sized 
or  large  town  if  it  lias  not  one  or  more  forest  recreation  places 
according  to  its  population. 

With  further  organization  it  would  be  desirable  to  arrange 
them  also  for  night  work  on  the  lines  of  the  American  sanatoria. 
The  "  night  camps,"  too,  are  very  useful,  as  thev  enable  work- 
women who  specially  suffer  from  the  bad  conditions  of  dwellings 
to  sleep  in  good  air  (Latz  and  Eflfter). 

But  how  far  are  we  from  a  national  prophylaxis  capable  of 
being  carried  out  and  answering  to  our  demands  ? 


308 


SCROFULOSIS 


Forest  Recreation  Places. 
•  Denotes  open  day  and  ni^ht.  t  Denotes  vpen  during  tlie  winter  also. 


V  ^  .. 
o   «   « 


o  c 

£8 


«     M      ( 


bjo 


PP 


Name  and  place  of  institution 
F.R.  P.  =  Forest  recreation  place 


Q-> 


*+Schneewalde,  nr.  Konigsberg  ... 

Heubude,  nr.  Danzig     ... 

Leopold  Koppel,  F.R. P. 
*tEichkamp,  nr.  Berlin     

*  Pankow,  nr.  Berlin 
Sadowa,  nr.  Berlin 

Wolf  Becher,  F.R.P.,  nr.  Berlin 

*  Scln'mholz  I,  nr.  Berlin 

*  Schdnholz  II,  nr.  Berlin 

Schoneberg    I,    nr.     Eichkamp- 
Ciriinewald 

*  Schdneberg    II,    nr.    Eichkamp- 

Griinewald 
t  Madlower  Ileide,  nr.  Kottbus  ... 
t  Spandau  II 

*  Westend,  nr.    Eichkamp-Griine- 

wald 
•tMiidchenhort  Eberswalde 

Kunigsheide,  nr,  Johannisthal  ... 

Forst  Lausitz 

Hohenkrug  II,  nr.  Stettin 

*  Jeeser,  nr.  Griefswald     

t  Unterberg  II,  nr.  Moschin 
Unterberg  III,  nr.  Moschin 

Karlowitz,  nr.  Breslau    ... 
Oswitz,  nr.  Breslau 

*  Krampe,  nr.  Griinberg 

*  Bunzlau,  in  Silesia 

*  Gorlitz      

Derschau-Oppeln 

**  Glogischdorf,  nr.  Glogau 

Haynau 

Rogatz,  on  the  Elbe 

*  Halberstadt  

*  Markische    convalescent    home, 

Luisenheim,   nr.   Kuhfelde 
JMagdeburg-Sudenljurg  Fort  II 
Dolauer    Ileide,    Halle    on    the 

Saal 

Vinnhorst,  nr.  Hanover 
Misburg,  near  Hanover 

*  Harburg,  on  the  Elbe 


Number  of  inmates 


Women      Children 


20 
150 

250 
250 


250 

250 

250 

.     30 

infants 
150 

200 


80 — 100 
Projected 


30 
60 


I      240 

no 

10 

Children 


70—80 


75 


50 

20 

Women 


35 

23 

100 


ISO 
30 


I       75 

Children 
j     120 

Children 
I       12 

Children 

Children 

30 

50 

45 

Children 

I         22 

Children 
20 


Children 
150 


Amount  charged  in  marks 


1.50  for  women 
1. 10  for  children 

Summer  0.55 
Winter  0.70 
0.55,  full  board  i.io 
0.30—0.50 
0.30 — 0.50 
0.30 — 0.50 
1.25  for  children 


0.80,  or  1.70,  including 

lodging 

1.50  free  patients 

0-55. 
0.5  for  children 

i.o 

0.75  for  children 

0.60  for  dinner  and 

I  litre  milk 

2.0  for  board  and  lodging 

1.50 

2.0  with  lodging 

1.40 


1.0 — 1.40 

1.0 — 1.40 

1.80 

1.50 

2.0  with  lodging 

0.60 — o.go  with  fare 

1.50 

0.60  for  children 

1.60  for  women 

Planned 

0.60 

1.20 

1.0  club  price 

1.50  for  children 

2'75  for  women 

0.50—0.80 


0.20 — 0.30  dinner 

0.20—0.30  dinner 

According  to  meals  taken 


I'ROI'llYLAXIS 

KOKKSr    Rk/.'KKA  TION    I'l.A'.KS       (Oil ti lliud. 


309 


11    rt 


Pi 


M 


Nainu  and  plucc  of  iiihtitulio]! 
I''.  U.P.  =  Forest  recreatiiiti  place 


*  Siilldorf,  nr.  Blankenese 

*  Viehburg,  nr.  Kiel 

"   Weidenaii,  nr.  Siegen    ... 
Ilerford  in  Westphalia  ... 

*  Cassel  II  ... 

*  Gissellll  

Frankfuit-on-Main 
Wieshaden-Chausseehaus 

tM. -Glad  bach       

Dilsseldorf  II 
Diisseldorf  III     ... 
Burgholz  II,  nr.  Elberfeld 

*  Wap[ielsberg,  nr.  Berg-Gladbach 
Hochbend,  nr.  Crefeld  ... 

Ohligs       

Stadtwald     in     Jagenburg,     nr. 

Solingen 
Bonn 
Holzapfelkreut,  nr.  Munich 

*  Josephine  Abel's  F.R.P.,  Holz- 

apfelkreuth,  nr.  Munich 
Frida       Schramm       Institute, 

Riickersdorf,  nr.  NiirnlDerg 
Further     Stadtwald,    Furth     in 

Bavaria 
Weissenburg  in  Middle  Franconia 
Aschaffenburg 
F.R.P.  King  Frederic  Augustus, 

Chemnitz 
Freiberg  in  Saxony 
Stotteritz,  near  Leipzig  ... 
Marienberg  in  Saxony    ... 
Zwickau    ... 

Mannheim  II,  Neckarau 

^l  Dieterschlag,  nr.  Darmstadt  II... 

t  Dessau  I   ... 
Dessau  II 

Treben,  nr.  Altenburg   ... 
Sonneberg 

Kattenturm  II,  nr.  Bremen 
Wesloe  II,  nr.  Liibeck  ... 


Strassburg  I 
Strassburg  II 


Niiiiibcr  of  iiiiii.it': 


Women      Children 


75       I      - 
100 


20 
70 


35 
IChildren 

70 
Children 


Children 


150 

50 
100 

50 
To  be  opened 

50       I       - 

—  30 

50  — 

—  I       20 

To  be  opened 

Projected 

150 

50 


300 


Children 


50 


Projected 

Projected 

50       I       30 

Opened  in  191 1 

36       I       — 

Women 

IS 


50 

20 
20 
20 


Children 


Projected 


Women 


50 


50 

100 


A  mount  charged  in  marlcH 


1.70—2.50 

0.85  for  children 

l.o  for  women 

25.0  for  4  weeks 

Projected 

1.50 

1.25  with  instruction 

1.30 

1.25  —  1.50 

1.0—2.0 

2.0 

2.25 

1.50 

1.50 — 2.0 


0.70  for  children 

0.70  for  day's  food, 

1.50  food  and  lodging 

1.50  including  fare, 

children  less 
1.50  including  fare 


1.60 


1.30 


0.65 

1.20  for  private 

1.0 — 1. 10 

0.20  dinner  at  cost  price 


0.60  for  children 
i.o  for  women 


1.60 
1.70 


3IO  SCROFULOSIS 

Forest  Recreation  Places  for  Men. 

Jungfernheide,  nr.  Charlottenburg.  Wst.  Luise  v.  Studt,  Johaiinislhal.  Madlower 
Heide,  nr.  Kottbus.  Spandau  I.  Forst  Lausilz.*  Hohenkrug  I,  nr.  Stellin.  Unter- 
berg  I,  near  Posen.  Oplawitz,  nr.  Bromberg.  Karlowitz,  nr.  Breslau.  Krampe,  nr. 
Griinberg.*  Bunzlau,  Silesia.*  Gorlitz*  Derschau-Oppeln.*  Ilaynau,  Silesia.  Moser, 
nr.  Magdeburg.  DoUaucr  Heide,  nr.  Halle.  Halberstadt."  Quediinburg.*  Vinnhorst, 
near  Hanover.  Harburg  on  the  Elbe.  Sulldorf,  Holstein.*  Herford  Westphalia. 
Cassel  I.  Frankfort-on-Main.*  Chausseehaus,  nr.  Wiesbaden.  M.-Gladbach.* 
Cologne-on-Rhine.  ■  Diisseldorf  I.  Burgholz  I,  nr.  Elberfeld.  Aix-la-Chapelle.  Hoch- 
bend,  nr.  Crefeld.  Bonn.  Rheindorf,  nr.  Bonn.  Frieda  Schramm  Institution,  nr. 
Niirnberg.  •  Fiirlher  Stadtwald,  Fiirth.*  King  Frederic  Augustus,  Chemnitz.* 
Stutleritz  I,  nr.  Leipzig.  Zwickau.*  Eltlingen,  Baden.  Mannheim  I.  Waldhof. 
Lenzenhiilte,  nr.  Darmstadt.  Jena.  Dessau  1.*  Dessau  H.*  Treben,  nr.  Altenburg. 
Kattentutm  I,  near  Bremen.     Wesloe  I,  nr  Lubeck.     Strassburg  H. 

Those  marked  *  take  both  men  and  women. 

From  the  foregoing  list  of  the  existing  forest  recreation  places 
in  Germany,  with  a  few  interesting  statements  taken  from  the 
account  of  the  German  Central  Committee  for  combating  tubercu- 
losis, we  see  that  for  the  present  we  have  only  98  forest  recreation 
places,  eleven  of  which  are  open  in  winter,  containing  :  — 


Women 

room  f 

or   I 

,517  in  12 

Children       

3) 

2 

,329  „   17 

Women  and  children 

3) 

I 

,000  ,,   12 

Men,  women  and  children 

610  ,,   16 

Men  and  women 

J3 

585  ,,   10 

Men    and    children 

33 

240  ,,     2 

Men    (only   for   men) 

,, 

2 

,375   ,,   18 

We  will  exemplify  from  Berlin  how  much  remains  to  be  done, 
even  in  highly  advanced  communities. 

The  amount  of  taxes  paid  gives  a  certain  insight  into  the 
social  position,  and  therefore  to  the  dwelling  conditions  which 
are  dependent  on  it.  In  Berlin,^  for  example,  in  1906,  in  a 
population  of  1,991,658  persons,  there  were  1,112,397  hable  to 
income  tax.  Of  this  number  509,523  were  exempt,-  their  income 
being  under  900  marks  (;^45). 

We  had  in  Berlin  (in  1905)  :  — 

Children   under    14  years          ...         ...  ...  ...  470,549 

Of  these  there  were  : — 

Under  2  years ...  ...  ...  74,574 

From    2    to    6    years   ...         ...  ...  ...  137,374 

,,        6    to  14       ,,       ...  ...  258,601 

Reckoning  from  former  statistical  annuals,  about  42  per  cent, 
of  the  total  of  children  would  belong  to  those  persons  exempt  : 

'  I  am  indebted  to  the  kindness  of  the  Berlin  Statistical  Office  for  these 
records,  for  which  I  here  express  my  heartiest  thanks. 

'  Including  10,711  who  were  exempt  on  account  of  very  large  families 
and  small  incomes. 


I'Roi'ini.Axis  3«i 

Thus  about  197, ooo  diildrcn  (an  un(<Miain  r<)iii|)nlal  ion,  I  allo'Aj 
of  parf;nls  will)  a  yearly  incoinc  Miidcr  (/jo  marks,  and  \\\cr<'U>r(' 
living  in  j^cnurv. 

Now  in  Berlin,  besides  fort-sl  rccreaiion  plares,  lliepe  are 
some  iorl\-dire<'  inslilutions  for  ilie  (are  of  younj:^  cliildren, 
thirty-one  kinder<j;-arlens,  six  cn'-ches,  ihiriy-two  refuges  for  ehil- 
dren,  twentv-eight  refuges  for  girls  :  these  shelter  from  9,000  to 
10,000  children  during  I  he  day.  The  other  187,000  children,  who 
live  in  poverlx,  are  in  most  cases  condemned  to  small,  unheallhy 
rooms  which  in  many  instances  jjcggar  description.  J'erhaps 
scruples  of  an  ethical  antl  material  nature  will  be  brought  to  bear 
against  our  demands  for  further  development  of  kindergartens 
and  special  forest  recreation  places,  which  on  closer  consideration 
will  pro\e  themselves  invalid. 

Will  not  the  feeling  of  responsibility  of  the  parents  be  dulled 
by  a  far-reaching  care  of  the  children  by  societies?  Will  not 
carelessness  and  idleness  be  encouraged  in  mothers  if  we  take 
part  of  the  burden  of  the  children  off  their  shoulders? 

That  would  be  the  case  if  the  mother  had  the  choice,  the 
possibility  of  caring  properly  for  her  child.  But  by  far  the  greatest 
number  of  those  cases  which  we  are  now  considering  are  mothers 
who,  by  the  necessities  of  life,  are  forced  to  help  to  earn  their 
living  either  at  home  or  outside,  and  are  obliged  to  leave  the 
children  to  themselves.  We  have  to  reckon  with  conditions  as 
they  are;  the  children  are  there  once  for  all,  and  the  demand  to 
restrict  the  number  of  children  for  reasons  of  economy  has,  un- 
fortunately, in  later  years  been  obeyed  more  than  is  desirable  in 
the  interests  of  the  nation,  as  we  perceive  from  the  reduction  of 
the  figures  in  the  birth-rate.  The  more  we  make  the  keeping  of 
the  children  easy  for  the  mothers,  and  the  more  we  advance  and 
ensure  their  bringing  up,  the  more  we  provide  w-ith  far-reaching 
vision  for  the  future  of  the  nation.  We  see  what  efforts  France 
is  making  to  keep  up  the  numbers  of  her  few  children,  and  what 
gloomy  fears  we  frequently  hear  uttered  in  her  press. 

But  is  not  the  great  mortality  amongst  children  an  advantage 
economically,  inasmuch  as  it  weeds  out  the  weaklv,  and  leaves 
only  those  capable  of  resistance,  who  then  grow  up  a  sturdv  race? 
If  this  were  really  so,  then  the  ethical  justification  of  exposing  the 
children  to  the  wretched  condition  of  their  dwellings  like  a  modern 
Taygetus  might  be  left  to  subjective  feeling.  But  this  weeding 
out  is  partly  only  a  chimera  of  the  study-table  and  is  verv  problem- 
atical, for  it  is  well  known  that  many  children's  diseases  snatch 
away  the  strongest  and  leave  the  weakly  ones  behind. 

Besides,     we     do     not     lav     on     kindera^artens     and     forest 


31^ 


SCROFULOSIS 


recreation  places  the  task  of  loringing  up  the  weakly  children  at 
the  expense  of  a  workl  of  trouble,  for  that  they  are  not  capable 
of  accomplishing,  but  that  they  should  primarily  protect  children 
who  have  hitherto  been  healthy  from  most  severe  hygienic  ills 
by  the  enjovment  of  fresh  air  and  by  a  suitable  mode  of  life, 
for  children  are  inevitably  exposed  to  such  ills  at  home,  and  the 
strongest  succumb  to  them ;  our  duty  is  to  harden  the  children, 
strengthen  them,  and  nip  diseases  in  the  bud. 

The  fear  that  through  such  kindergartens  and  forest 
recreation  places  the  spread  of  children's  diseases  would  be  more 
favoured  than  it  would  be  in  their  small,  wretched  homes  can  be 
just  as  little  entertained  if  only  care  be  exercised.  On  the  con- 
trarv,  we  see  that  measles,  scarlet  fever,  Sec,  have  decreased 
during  the  school  years  in  a  most  striking  manner,  when  we 
contrast  the  statistics  with  those  of  former  years  when  our  children 
lived  more  at  home. 

In  Prussia,  in  1906,  of  10,000  living  there  died  of  scarlet 
fever,  measles,  German  measles  and  whooping-cough — 

Under  i  yr.       i  to  2  yrs.      2  to  3  yrs.      3  to  5  yrs.       5  to  10  yrs.       10  to  15  yrs. 
ii2'o  74'5  29'o  i7'3  7'o  i'6 

The  doubt  whether  children  are  really  much  benefited  through 
such  apparentlv  half  measures,  if  they  are  only  taken  from  the 
conditions  of  the  parents'  houses  for  a  time,  but  are  at  home  in 
the  evenings  and  at  night,  is  completely  unjustifiable.  The  benefit 
is  incontestable.  As  I  have  already  remarked  on  other  occasions 
the  great  hygienic  ills  must  be  mathematically  investigated  and 
analysed  quantitatively.  According  to  the  laws  of  probability,  to 
speak  onlv  of  infection,  a  person  is  only  half  as  much  endangered 
by  an  exposure  to  it  of  twelve  hours  than  one  of  twenty-four  hours. 
But  in  our  case  the  conditions  are  much  more  favourable.  With 
a  child  who  leaves  the  house  in  the  morning  before  the  dust  has 
been  disturbed  by  sweeping,  and  returns  only  at  night,  when  no 
dust  is  raised  and  when  the  air  is  freest  from  germs,  the  danger  is 
reduced  to  a  minimum  (for  full  reasons,  see  G.  Cornet,  "  Die 
Tuberculose,"  second  edition,  p.  398). 

Every  hour  outside  the  house  reduces  the  harmful  influence, 
and  especially  reduces  the  dangers  of  tuberculo-scrofulosis. 

The  hygienic  benefit  is  incalculably  great  if  the  children  are 
not  all  day  in  an  unhealthy  home,  in  foul  air,  in  a  dirty  environ- 
ment full  of  germs,  or  playing  on  the  dusty  stairs  w'hich  have  been 
spat  on,  or  in  the  courts  and  streets  with  no  one  to  look  after  them, 
and  exposed  to  all  sorts  of  dangers ;  if  they  have  not  to  be  fed  with 


I'l;' M'llYI.AXIS  3 '3 

a  |)i(;cc,  of  bread  spread  willi  iii.'ir^.'iriix-  (hemiise  llie  niollx-r  is 
nol  there'  Lo  cook),  bill  ;ire  in  llie  Iresli  ,-iir,  \\>-\\  lool-:ed  after,  pass- 
ing their  lime  in  iniKicent  play,  hardened,  regularly  fed  and 
washed,  llie  prol<M  ii\c  means  against  scrofuhtsis  and  ihe  founda- 
tion of  a  healthy,  r(;sisl.-ini ,  able  m;in   is  l;iid. 

And  with  what  few  .'ind  simpU;  means  is  that  which  may  be 
called  llu;  hygienic  righl  of  children  to  be  attained,  only  with  a 
small  fraclion  of  die  cosl  of  llie  expenses  which  yearly  must  be 
laid  out  for  sickness,   ill-h(;allh,  and  j)urial  ? 

Kindergartens  must  be  extended  and  increased,  removed  to 
the  outskirts  of  cities  and  differenlly  organized,  on  I  he  lines  of 
the  forest  recreation  places,  then  they  will  benelli  one  and  all. 
Through  tiie  education  of  the  caretakers  who  are  i rained  for  the 
work  in  proper  schools,  and  amongst  whom  it  is  lo  be  hoped  will 
be  found  the  daughters  of  the  better  classes,  a  large  number  of 
hygienic  and  instructive  ideas  for  the  education  of  children  will  be 
spread  amongst  a  wide  circle,  and  the  pitiful  ignorance  of  many 
mothers  and  nurses  about  the  regulations  given  by  doctors  for  the 
avoidance  of  scrofulosis  and  the  care  of  children  generally  will  be 
mitigated. 

I  will  not  here  enter  into  the  further  advantages  on  ethical 
and  educational  grounds,  on  the  protection  of  children  from 
moral  infection,  on  the  national  economical  side  that  the  mother 
will  be  freer  in  her  work  without  blunting  her  feelings  by  her 
inability  to  give  sufficient  care  to  her  children,  and  that  home 
comforts  will  be  increased,  &c. 

The  question,  in  what  manner  and  with  what  means  these 
kindergartens  are  to  be  instituted,  answers  itself  by  considering 
whose  interests  it»furthers.  Private  charit}-  alone  is  not  able  to 
grapple  with  the  new  task  to  the  desired  extent.  The  parents, 
who  are  freed  from  the  burden  of  their  children  at  home  and  have 
the  greatest  interest  in  the  health  of  their  children,  must  be  called 
upon  to  at  least  a  moderate  degree  for  the  cost  of  their  care  and 
upkeep. 

The  whole  of  society,  the  district,  and  the  State  have  hardlv 
less  interest  in  the  health  of  those  belonging  to  them. 

Besides  the  losses  which  cannot  be  calculated,  the  losses  in 
mental  and  moral  capital,  the  State  suffers  a  considerable  vearlv 
economical  loss  by  the  mortality  amongst  children,  which  is  in 
direct  proportion  to  the  expenses  incurred  for  food  and  bringing 
up  of  the  child  (the  so-called  cost  value  of  a  man)  which  have 
been  rendered  useless.  These  costs  are  not  covered  later  by  the 
work  of  the  man,  and  so  are  a  national  economic  loss,  amount- 
ing everv  vear  in   Prussia  alone   from   scrofulosis,    tuberculosis. 


3M 


SCROFULOSIS 


pulmonarv  caiarrli,  measles,  scarlet  fever,  &c.,  in  short,  from 
diseases  which  are  considerably  favoured  by  bad  dwelling  con- 
ditions, to  at  least  20,000,000  marks  (;^' 1,000, 000)  for  110,744 
children  under  10  years  of  age  who  have  died  (according  lo  a 
reckoning  given  in  another  place,  and  the  further  consideration 
of  which  here  .would  lead  us  too  far). 

In  addition  to  this,  the  considerable  reduction  in  the  power 
of  defence  of  the  land  must  be  taken  into  consideration,  as  the 
greater  part  of  those  born  do  not  reach  the  age  at  which  they 
could  carry  arms,  or  are  so  weakened  by  the  unfavourable  con- 
ditions under  which  they  live,  that  they  must  be  set  aside  as 
incapable  of  military  service. 

The  great  harm  done  every  year  to  the  health  of  the  population 
by  scrofulosis  and  other  diseases  favoured  by  the  w^retched  dwell- 
ing conditions,  the  national  economical  harm  arising  from  this 
grievance,  the  impossibility  of  radical  improvement  by  other 
means  (as  a  century  of  trial  of  measures  recommended,  but  which 
have  proved  useless,  shows),  this  point  of  view  makes  it  the  duty 
of  the  State  and  of  the  community  to  seriously  prepare  a  way 
towards  improvement,  on  the  lines  here  given,  of  hygienically 
arranged  peoples'  kindergartens,  and  especially  of  forest 
recreation  places,  and  also  makes  it  the  duty  of  us  doctors  to  help 
in  the  w-ork  by  instructing  influential  circles.  We  might  then 
hope  to  save  everv  vear  a  not  inconsiderable  part  of  the  living 
victims  and  material  sacrifices.  It  appears  to  be  a  special  duty 
for  those  doctors  who  consider  the  predisposition  created  in  youth 
to  be  the  chief  cause  of  the  scrofulosis  and  tuberculosis  which 
appear  later,  to  prevent  this  original  predisposition  in  an  effective 
manner,  to  strike  at  the  root  of  the  evil,  and  jit  must  especially 
affect  those  doctors  who  consider  that  the  chief  cause  of  infection 


is  due  to  overcrowding. 


For  mineral  baths,  seaside  homes,  and  holiday  camps  which 
occupy  a  large  place  in  the  combat  against  scrofulosis,  see  Thera- 
peutics (p.  .',31). 


chaptI':r  II. 
THE  CHILD  AT  SCHOOL 


A  GREAT  and  gratifying  task  falls  to  the  sc  Imol  in  iIh-  prop;l)y- 
laxis  of  scrofulosis.  I  will  not  here  enter  more  (  losel y  into  tlie 
claims  of  general  hygiene  demanded  in  school  buildings  with 
respect  to  pure  and  sufficient  air,  cleanliness  (prophylaxis  in  the 
matter  of  sputum),  duties  which  are  incumbent  on  the 
community,  and  which  result  from  compulsory  education ; 
these  are  fully  treated  of  in  manuals  on  school  hygiene  (for 
example,  Baginsky,  Wehmer,  and  others).  At  any  rate,  the  venti- 
lation must  be  permanent,  and  not  left  to  the  whim  of  teachers  who 
are  afraid  of  air ;  ventilation  must  take  place  thoroughly  in  the 
intervals  between  the  lessons,  cleaning  must  be  done  sufficiently 
often  and  always  with  damp  cloths,  not  in  the  morning  before 
the  commencement  of  studies,  but  after  the  school  hours  are  over. 
To  prevent  dust,  the  use  of  dust-combining  materials  is  recom- 
mended; for  example,  dustless  oil,  or  similar  preparations  which, 
as  they  become  ineffective  after  some  weeks,  must  be  renewed 
from  time  to  time.  During  school  hours  a  proper  position  of  the 
body  must  be  insisted  upon,  especially  with  girls  when  sewing. 

The  demands  of  the  school  must  be  sensible,  and  such  as 
are  suited  to  the  later  necessities  of  life.  Many  complaints  are 
made,  and  rightly  so,  of  overburdening  the  children  with  home- 
work, which  often  occupies  even  the  child  of  average  cleverness 
till  late  at  night,  shortening  the  time  for  sleep  (which  in  the  early 
vears  of  development  must  be  from  ten  to  twelve  hours),  and 
leaving  insufficient  time  for  recreation  in  the  open  air.  The 
natural  consequences  of  such  mental  overburdening,  the  failure 
of  nutrition  and  development,  and  other  consequences  prepare  the 
way  for  scrofulosis.  The  (school)  doctor  must  influence  the 
decision  as  to  the  quantitv  of  home-work  allowable,  for  doctors 
have  the  products  of  mistaken  education,  the  cripples  in  body  and 
mind  brought  under  their  notice.  Between  each  lesson  there 
should  be  a  pause  introduced  for  recreation,   which   the  scholar 


3l6  SCROFULOSIS 

sluuikl  siH'iul  ciilicr  in  ihe  phu'groiinci,  or  in  hud  weailier  in  the 
gymnasium. 

X(U  less  impnriani  in  ilic  propln  laxis  ot  scntfulusis  is  thai 
which  is  tlie  thsiincn  task  nl'  ih''  srhool,  not  on\\  the  care  i)f  the 
mental  training,  which  is  often  clone  very  one-sidedly,  but  also 
the  charge  of  the  hodil\-  development  of  the  vouth  under  its 
care.  The  natural  aim  of  the  school  is  to  step  in  and  help  to 
complete  the  work  where  the  home  training  fails;  it  must  not  be 
indifferent  to  ancumia,  bodily  weakness,  reduced  development  of 
the  miisc-les,  and  other  signs  (^f  pliNsical  deterioration  caused  by 
working  too  long  seated  at  a  desk. 

We  know  now  of  the  scrofulous  tendency,  be  the  cause  of  it 
what  it  mav,  that  it  disappears  with  increasing  development,  and 
is  hardl}'  ever  present  in  adults.  Therefore,,  to  advance  bodily 
development  is  one  of  the  first  laws  of  clear-sighted  prophylaxis. 
For  this  reason  obligatory  gymnastics  (in  the  open  air),  plaving 
out  of  doors,  cycling,  swimming,  skating,  sliding,  football,  lawn 
tennis,  cricket,  racquets,  and  so  on  are  urgently  recommended, 
of  course  in  a  degree  suitable  to  the  age,  and  avoiding  any  excess. 

Proper  gymnasia  and  playgrounds  are  a  requisite  for  every 
school,  both  in  the  interest  of  avoiding  scrofulosis  and  otherwise, 
demands  which  advanced  school  committees  have  recognized  in 
practice.  Drill  halls  should  only  be  used  in  case  of  necessity,  on 
account  of  the  greater  collection  of  dust,  which  is  unavoidable. 

The  present  generation  of  educationists  do  not  keep  them- 
selves entirely  aloof  from  the  idea  of  the  necessity  of  attention 
to  the  bodily  care  and  development  of  youth  ;  many  stand  side 
by  side  with  the  hygienists  and  stri\'e  manfully  for  their  cause. 
The  institution  of  a  prize  for  boat-races  for  schoolbovs  bv  the 
Emperor,  and  in  Bavaria  by  the  Regent,  has  had  an  extraordinary 
effect  in  furthering  games  for  young  persons. 

Even  now  the  greater  number  of  our  schools  limit  the  whole 
of  their  physical  instruction  to  a  few  hours  in  gymnastics,  others 
have  the  superintendence  of  games  in  their  curriculum,  and  in 
girls'  schools  too  special  hours  are  set  aside  for  instruction  in 
games.  The  number  of  teachers  (male  and  female)  who  have 
gone  through  a  course  of  training  for  games  in  Germany  gives  a 
general  idea  of  the  extension  of  the  movement.  There  were,  in 
1890  and  1896,  1,672  and  3,260  respectivelv. 

The  goal  for  which  we  should  stri\-c  should  be  that  the 
morning,  commencing  at  (seven  or)  eight  o'clock,  be  devoted  to 
lessons,  with  the  necessary  short  pauses  for  airing  and  resting, 
but  that  the  afternoon  should  be  left  for  bodilv  training  (at  least 
two  hours  daily),  and  home-work  should  bo  reduced  to  a  definite 
amount. 


1'I<01'I1VI,AX(.S  317 

IIk:  benelil  \vc  di-rwc  from  <)l)li^^'lt()ry  [jlissical  training, 
quoiid  saniUiicm,  is  tvvc^fold,  noi  only  the  direct  advantages 
which  we  can  .ippicciaU;  al  once,  on  which  I  need  waste  no  words, 
but  also  a  great  indirect  advantage,  l)ecause  the  child  of  the 
(middle  and)  poorer  classes  is  removed  from  the  unhygienic  home 
ccjndilions,  the  small  rooms,  and  the  menaced  danger  of  infection 
there,  for  at  least  a  few  nicjre  hours — a  fact  which  is  so  important 
for  I  he  avoidance  of  scrofulosis. 

The  school  gardens  and  playgrounds,  and  in  bad  weather 
the  well-appointed  g\innasia,  which  must  be  provided,  especially 
in  town  schools,  should  be  left  open  to  the  scholars,  especially  the 
younger  ones,  out  of  scIkjoI  hours,  on  Sundays  and  on  holidays, 
for  a  playground,  especially  during  the  holidays  when  the 
children  are  under  no  superintendence,  and  often  get  into  all 
sorts  of  mischief  to  the  annoyance  of  the  parents;  the  introduction 
of  holiday  excursions  and  holiday  games  might  be  considered, 
conducted  by  the  teachers  or  persons  especially  qualified  for  it, 
such  as  have  been  started  in  some  of  the  Rhenish  provinces,  and 
which  have  been  so  highly  successful.  Thev  offer  a  substitute,  if 
only  a  poor  one,  for  holiday  camps. 

Every  school  should  take  a  pride  in  possessing  its  own 
recreation  and  playground  in  the  nearest  wood,  on  common  or 
State  land,  which  should  be  open  to  the  pupils  on  half  holidays, 
Sundays,  and  in  the  vacations,  needing  only  to  be  proxided  with 
a  shelter  for  sudden  storms;  holiday  camps,  homes,  <S:c.,  which 
give  children  of  the  poorer  classes,  especially  the  weaklv  ones  and 
those  suspected  of  scrofulosis,  the  desired  opportunity  of  spending 
a  few  weeks  of  the  rear  in  the  country  and  forest  air,  will  be 
spoken  of  under  "Therapeutics";  by  such  care  poor  children 
xvould  be  removed  from  the  danger  of  unhealthy  dwellings  and 
protected  from  the  harmful  effects  of  the  streets. 

School  Baths. — Regular  bathing  is  urgentlv  demanded  as  a 
means  of  education  and  cleanliness,  also  as  a  means  of  avoiding 
disease,  but  especially  for  the  avoidance  of  scrofulosis.  How, 
in  the  small  houses,  can  the  elder  children,  even  of  middle-class 
people,  get  a  bath,  to  sav  nothing-  of  the  families  of  the  work- 
people ? 

What  is  the  good  of  all  the  preaching  about  the  practice  of 
cleanliness  and  care  of  the  skin  when  not  the  slightest  arrange- 
ments are  made  to  fulfil  the  demand  ?  A  short  time  ago  there 
were  in  Germany  1,131  warni  bath  establishments  to  32  million 
inhabitants — i  for  30,000  persons.  The  prices  charged  are  some- 
times so  high  that  the  frequent  use  of  them  is  denied  to  the 
great    mass   of   the    people    who    require    them   most.      In    other 


3lS  SCROFULOSIS 

coLinlries  things  were,  and  still  are,  worse,  fn  Rome,  the  city 
of  the  warm  baths  of  Caracalla  and  Tilus,  some  years  ago  I 
knocked  in  vain  at  the  door  of  three  baths,  they  were  closed 
during  the  winter. 

In  recent,  years  there  has  been  a  satisfactory  change  for  the 
better,  especially  in  Germany;  the  Berlin  Society  for  People's 
Baths  has  done  great  service  in  this  matter;  the  object  of  the 
Society  is  to  arrange  for  cheap  and  even  free  baths,  and  in  its 
buildings  only  25  pfennig  (3d.)  is  charged  for  a  bath  and 
10  pfennig  for  a  shower  bath.  Thanks  to  these  endeavours, 
Germanv  has  become  an  example  to  other  countries  by  the  institu- 
tion of  numerous  baths  (even  if  the  number  be  still  insufficient) 
for  the  people,  for  factory  hands,  and  for  barracks. 

The  idea  of  introducing  baths  for  the  young  people  who  go 
to  school — school  baths — was  first  carried  into  practice  by  Ober- 
biirgermeister  Merkel  in  Gottingen  in  the  year  1886;  he  arranged 
them  there  in  the  simplest,  and  in  the  cost  and  w-orking  the 
cheapest,  and  therefore  the  most  practical  manner,  as  shower 
baths.  The  conception  that  it  was  the  right  thing  for  the  school 
to  train  youth  to  cleanliness  and  to  the  care  of  its  health  at  last 
conquered  the  many  doubts  and  difficulties  which  educationists 
at  first  raised  as  to  the  advisability;  the  results  completely  silenced 
all  objections. 

The  tirst  shower  bath  in  Berlin  was  opened  in  1894  in  the 
Government  municipal  schools;  up  to  1899,  eighteen  schools  and 
nine  "  mixed  "^  schools  had  followed  the  example,  and  to-day 
hardh'  a  new  municipal  school  is  opened  that  has  not  its  shower 
baths.  Thev  are  open  to  the  scholars  free,  including  soap,  once  a 
week,  and  are  fully  appreciated  by  the  children.  Success  was 
claimed  both  hvgienicallv  and  educationally,  in  that  children  with 
dirtv  and  ragged  underclothing  were  ashamed  of  it  and  came  with 
decent  clothing, 

A  further  extension  of  baths,  their  introduction  into 
"  middle  "  schools  (iNIittelschule),^  but  especially  into  kinder- 
gartens— which  up  till  now  have  been  very  badly  treated  in  this 
respect — is  required  on  general  hygienic  grounds,  and  pressinglv 
needed  for  the  avoidance  of  scrofulosis. 

School  Feeding. — The  well-known  fact  that  school  children 
are  often  underfed  and  frequently  come  to  school  without  break- 
fast, and  because  the  parents  are  at  work  must  content  themselves 

'  ''Mixed"  schools  (Doppelschule)  correspond  as  nearly  as  possible  to 
the  schools  in  England  taking  boys  and  girls  together;  "middle"  schools 
correspond  to  the  County  Council  Schools. — Translator. 


I'KOI'IIYLAXIS  319 

lor  a  whole  tlay  wilii  a  piece  ol  hrc.-id,  in  rc(  cml  years  lias  brouglit 
ahoiii  iIh;  feetlin<j;'  ol  ilic  pooiiT  (  liildrcn  m  many  [)la(:es,  a  result 
whieli  is  also  im|)oiia,ni  iVoni  llie  |)oini  ol  view  of  avoiding 
scrofulosis.  The  (;liiklr(;n  are  gi\cn  a  simple  midday  me-ai  in  the 
school;  rice,  semcjlina,  peas,  leniil  and  bread  soup  containing 
meat,  or  rice  milk-,  or  a  howl  ol  milk,  eggs,  vermicelli  and  grated 
cheese;  besides  vvhicli,  in  man\  places,  a  hot  breakfast,  bread  and 
milk,  widi  llie  addition  ol  mail  coffee,  cocoa,  &c.,  and  at  lunch 
time  £1  piece  of  bread.  A  (ommencemeni  has  been  made  of 
having  the  food  prepared  by  the  girls  of  the  higher  classes  in 
the  school  kitchens;  in  others,  wliere  this  arrangement  cannot  be 
carried  out,  the  feeding  might  be  done  in  connection  with  the 
people's  kitchens.  School  feeding  appears  to  find  its  best 
development  in  Munich,  where  it  has  been  introduced  through 
the  initiation  of  Oppenheim.  There  are  twenty-two  soup  kitchens 
in  that  town. 

School  Dootof. — There  are  so  many  hygienic  cjuestions  to 
solve  in  modern  schools  that  the  work  can  only  possibly  be  done 
by  doctors  who  have  completely  studied  that  branch  of  science. 
A  part  of  the  duties  of  school  doctors  is  to  superintend  the  whole 
hygiene  of  the  school,  airing,  cleaning,  and  the  removal  of 
refuse,  &c.  Children  and  teachers  should  be  regularly  examined 
for  tuberculosis  and  scrofulosis;  persons  with  open  tuberculosis 
should  be  suspended  from  school  as  long  as  they  are  infectious 
(Kirchner,  A.  Fraenkel,  and  others),  and  should  be  sent  to 
suitable  institutions,  sanatoria,  convalescent  homes,  forest  schools, 
forest  recreation  places,  &c. 

Besides  this,  the  school  doctor  should  conduct  the  hygienic 
instruction,  and  especially  that  concerning  infection  from  tuber- 
culosis ;  leaflets  should  be  distributed  to  teachers  and  scholars ; 
and  by  parents'  evenings,  the  parents  and  relations  of  the 
scholars  should  be  instructed  in  hygiene ;  in  the  school  rooms 
coloured  pictures,  placards,  and  rhymes  (see  above,  p.  303)  should 
be  hung  up  of  a  kind  suitable  to  the  ages  of  the  children  ;  of 
course  the  school  doctor  must  have  decisive  influence  in  all  ques- 
tions of  hygiene  if  he  is  to  fulfil  his  duties. 

Forest  Schools. — Next  to  forest  recreation  places,  one  of  the 
.  most  important  weapons  in  the  fight  with  scrofulosis  and  tuber- 
culosis (as  well  as  other  diseases)  is  the  arrangement  of  forest 
schools ;  these  were  first  brought  about  on  the  suggestion  of 
B.  Bendix  in  Charlottenburg,  and  have  since  proved  very  bene- 
ficial in  several  other  places.  The  number  of  pupils  in  the 
Charlottenburg  Forest  School  has  risen  from  95  in  1904,  to  250, 
some   with   scrofulosis   and   open   tuberculosis,    who   have   about 


320  SCROFULOSIS 

2^  hours'  insiruciiun  daily  in  ilic  open  air  when  ihc  weallier 
permits;  they  are  fed  at  school  and  are  out  of  doors  all  day.  In 
many  forest  schools,  for  example  in  Mtihlhausen  in  Alsace,  the 
children  may  remain  all  night  in  the  school  (Bienstock).  Forest 
schools  and  forest  recreation  places  are  distinguished  by  the 
healthy  endeavour  to  create  institutions  free  from  all  hygienic 
objections  with  the  simplest  possible  outlay,  outward  show  not 
being  entertained.  The  schools  are  open  about  six  months  or 
longer,  till  the  cold  weather  sets  in. 

The  number  of  forest  schools  in  existence  is,  in  proportion  to 
the  need,  only  as  a  drop  of  water  in  the  ocean,  but  it  is  to  be 
desired  and  hoped  that  more  energetic  measures  will  be  taken  in 
this  matter  so  all-imporlant  for  the  de\elopment  of  }"outh  and 
for  the  prophylaxis  of  scrofulosis.  The  good  results  which  have 
been  obtained  by  us  in  the  open-air  schools  have  led  to  similar 
institutions  being  introduced  into  England,  which  work  with 
complete  satisfaction  (Johnson,  see  also  Kel}-nack  and  M.  Fijrst). 

Bv  erecting  forest  schools  the  removal  of  weakl}-  and  sickly 
children  from  the  ordinary  school  is  considerabl}'  facilitated, 
as  the  fear  that  their  education  will  be  entirely  neglected  is 
eliminated,  at  least  in  part. 

Forest  schools  for  children  of  the  people  are  :  Charlottenburg- 
Eichkamp  for  240  children  in  6  classes;  Ziegenhals  in  Silesia  for 
40  children;  Mildstadt,  near  Husum,  for  10  children;  Dortmund- 
M.  Gladbach  for  120  children;  Solingen-Burg  for  100  children, 
2  classes;  Elberfeld,  wnth  20  sleeping  beds. 

J.  Abel's  forest  recreation  places  :  Holzapfell-rreuth,  near 
Munich,  for  18  children;  Frida  Schramm  Institution  in  Riickers- 
dorf,  near  Nuremberg;  Dresden-Blasewitz,  planned  for  20  chil- 
dren; Glauchau,  projected  for  40  children;  Giessen,  2  classes; 
Wesloe,  near  Liibeck,  for  60  children  ;  ]\Iiilhausen,  in  Alsace,  for 
200  children;  Hohenlvchen,  in  the  Uckermark,  for  100  children, 
with  opportunities  for  learning  housekeeping  and  gardening. 

Forest  schools  for  scholars  needing  higher  educational  estab- 
lishments :   Charlottenburg-Eichkamp  IT,  for  120  bovs  and  girls. 


SECTION   VIII. 

Therapeutics. 


The  lasks  before  us  in  the  llierapeulics  of  scrofulosis  arc  the 
following  :  — 

(i)  To  do  away  with  the  abnormal  condilion  of  the  tendency 
to  scrofulosis,  the  local  diathesis,  which  we  have  termed 
embryonism,  or  heightened  infantilism,  by  raising  the  individual, 
so  to  speak,  to  a  higher  and  older  stage  of  his  development  as 
the  result  of  strengthening  the  body. 

(2)  To  keep  away  from  the  body  further  germs  of  infection, 
tubercle  bacilli  and  pyogenous  bacteria,  as  long  as  the  above 
condition  is  present. 

(3)  To  hinder  the  infection  already  existing  from  spreading 
further  in  the  body,  and  to  localize,  to  heal,  and  to  remove  the 
consequences  of  the  infection,  or  to  cause  them  to  encapsule. 

This  we  endeavour  to  do  by  the  method  of  general  strengthen- 
ing of  the  body  (by  general  therapeutics,  which  blends  in  manv 
instances  with  the  prophylaxis,  which  has  just  been  discussed), 
and  by  local  treatment. 

Thus,  with  a  scrofulous  patient  we  have  in  the  first  place 
to  improve  as  far  as  possible  the  general  hygienic  conditions  (by 
better  air,  nutrition,  &c.),  to  consider  a  stay  in  the  country  and 
the  use  of  mineral  or  sea  baths,  which  experience  has  taught  us 
are  favourable,  to  use  internal  medicines  which  have  stood  the 
test  of  time,  and  to  pay  the  greatest  attention  to  the  removal  and 
avoidance  of  local  affections. 


21 


CHAPTl'R  1. 

GENERAL  THERAPEUTICS. 


General  therapeutics  consists  for  the  most  jiarl  in  the  utmost 
attention  to  hygiene. 

To  sever  the  thread  of  a  ct)nlinuance  of  evils  which  might 
lead  to  fresh  infection  an  exact  investigation  of  the  conditions 
under  which  the  patient  fell  ill  is  of  special  importance  in  scrofu- 
losis.  We  must  not  content  ourselves  with  conhrming  one  of 
the  conditions  which  are  usuall}-  accepted  as  disposing  to  the 
disease,  but  must  critically  test  the  patient  as  to  his  whole  manner 
of  life,  his  habits,  good  and  bad  practices  (for  example,  picking 
the  nose,  and  such  like),  as  well  as  his  personal  and  material 
surroundings,  and  where  these  conditions  give  rise  to  the 
slightest  need  for  caution  on  hygienic  grounds  to  change  them  to 
the  greatest  extent  possible,  so  that  a  certain  impulse,  a  change 
of  feeling  is  produced  in  the  organism.  Change  of  air  and 
food  different  from  what  the  patient  is  used  to,  change  in  the 
mode  of  life  and  environment  (of  course,  within  the  limits 
demanded  by  hygiene),  have  been  attended  with  the  greatest 
possible  success.  Air,  light,  exercise  and  nourishment  are  the 
foundation  pillars  both  of  prophylaxis  and  therapeutics. 

What  good  results  may  be  obtained  by  the  siniplest  means 
is  shown  by  the  example  of  Ritter,  which  has  alreadv  been  men- 
tioned. In  1894  he  took  forty  scrofulous  children  out  of  the 
forest  of  houses  in  Berlin  every  afternoon  for  months,  to  a  grassy 
place  free  from  dust,  w'here  they  were  exposed  as  far  as  possible 
to  sun  and  sand  baths  and  did  phvsical  exercises  under  trained 
superintendents  (in  rainy  weather  in  a  hall).  Resides  their  home 
food,  the  children  were  given  rriilk,  fruit,  and  a  mixture  of  Lipanin 
and  malt  extract  with  2  per  cent,  lime  and  5  per  cent.  iron.  The 
result  was  a  remarkable  increase  in  weight,  increase  of  chest 
measurement,  and  involution  of  scrofulous  svmptoms.  In  the 
forest  recreation  places,  also  arranged  with  limited  means,  these 
favourable  experiences  have  been  repeated  a  hundredfold. 


iiii'KAi'ivi;']  ics  323 


NUTRITION. 


VV(;  have,  in  llic  Imnicr  scfiioii,  di.srii.s.sfd  cioseiy  lli<;  (*xacl 
rules  will)  iclcrcncc  lo  mil  ril  ion.  A  food  easy  of  dig(*.slion  and 
assimilation,  die  liniilaiion  ot  slaic  liv  foods  and  sugar,  and  tin; 
preference  for  an  animal  and  \  c^ciahU-  did,  which  we  desired 
as  precautions  for  a  lieahli\  (  liild  and  for  liie  suspect,  have  been 
emphatically  recommended,  and  bectjmc  an  important  law  for  a 
child  who  is  already  scrofulous.  The  food  for  die  first  monllis  must 
be  milk  and  preparations  fidm  milk;  later,  besides  milk,  brfjdi 
made  with  meat,  pounded  and  lincly  triturated  meal,  light  vege- 
tables (spinacli,  carrots,  cauliflower),  and  soft-boiled  eggs  may 
be  given.  I'otatoes,  chestnuts  and  pulse  are  only  suitable  as  a 
puree,  bread  is  be.st  given  toasted.  Dainties  between  meals  are 
not  allowable,  and  special  (-are  must  be  lalcen  that  meals  are  given 
regularly. 

Precise,  written  directions  for  diet  should  be  given,  and  one 
should  convince  oneself,  by  weekly  weighing,  of  the  success  of  the 
treatment. 

The  choice  may  be  given  of  :  — 

Breakfast  :  Cocoa,  milk,  malt  coffee,  gruel,  with  white  bread 
and  butter  (honey  or  marmalade),  and  a  compote  of  stewed  fruit. 

For  early  lunch  :  Bread  and  butter  with  fresh  or  stewed  fruit, 
or  a  small  glass  of  milk  or  an  egg. 

Dinner  :  Soup,  meat  or  iish,  plenty  of  vegetables,  especially 
green  vegetables,  fresh  fruit  or  stewed,  and  a  little  bread. 

In  the  afternoon,  a  small  glass  of  milk,  with  biscuits  or  toast, 
or  bread  and  butter,  with  fruit,  fresh  or  stewed. 

Supper  :  Milk  soup,  potato  puree,  dishes  of  rice,  semolina, 
mondamin,  fresh  vegetables,  fruit,  compote,  and  milk. 

For  these  meals  the  different  nutritive  preparations  (see 
pp.  290-1)  mav  be  used  according  to  need  or  choice. 

With  excitable  thin  children  plentiful  nourishment  with  easily 
digested  fats,  cream,  and  butter,  with  which  may  be  mentioned 
cod-liver  oil,  have  proved  of  service,  and  metabolism  is  to  be 
furthered  as  far  as  possible,  especially  in  the  case  of  scrofulous 
children,  by  fresh  air,  exercise  and  change  of  air.  In  the  exuda- 
tive form  the  limitation  of  fat  and  milk  with  the  exclusion  of 
eggs,  as  recommended  by  Czerny,  is  to  be  tried. 

Good  water  is  the  chief  beverage,  perhaps  widi  a  little  fruit 
juice;  to  give  wine  and  beer,  and  especially  spirits,  in  early  life, 
unless  they  are  specially  indicated,  is  harmful,  but  sometimes 
with  torpid  children  a  light  wine,  or  with  erethistic  children  wine 
or  beer  in  small  quantities  is  indicated.     In  diarrhcea  proper  diet 


324  SCKOFULOSIS 

is  generally  sufficient ;  it  it  coniiniie,  acurn  coffee  and  Bordeaux, 
or  an  astringent  Greek  wine,  e.g.,  Kamarite,  is  given,  from  a 
teaspoonful  to  a  tablespoonful  at  a  time. 

A  number  of  remedies  have  in  the  course  of  time  acquired 
reputation  for  markedlv  furthering  nuiriiion. 

Helps  to  Nutrition. 

In  the  first  place  comes  cod-liver  oil,  which,  on  account  of 
its  fatty  acid  contents,  is  easily  digested  and  assimilated,  and  is 
employed  preferably  for  thin  excitable  children  who  need  fats ; 
no  specific  effect  can  be  ascribed  to  its  iodine  as  it  contains  so 
little.  The  darker  kind  is  in  general  considered  more  effective 
on  account  of  its  containing  a  large  quantity  of  fatty  acid  (even 
6  per  cent.),  the  lighter,  clear  refined  oil  is  milder.  The  dose 
rises  from  one  to  three  teaspoonfuls,  if  it  suit  the  patient  three 
or  even  six  tablespoonfuls  may  be  given.  Many  children  like  it 
pure,  for  others  the  taste  of  the  oil  must  be  disguised,  for  which 
purpose  countless  more  or  less  good  correctives  are  recommended. 
The  simplest  is  the  addition  of  one  drop  of  oil  of  peppermint  to 
one  tablespoonful  of  oil  or  anise  oil  or  ethereal  oil  of  eucalyptus 
(2  drops  to  150  cod-liver  oil,  Duquesnel).  De  Pontini  recom- 
mends an  emulsion  of  one  tablespoonful  of  cod-liver  oil  with 
the  volk  of  one  egg,  one  or  two  drops  of  peppermint  oil  and  half 
a  tumbler  of  sugar  water.  Kanzler  recommends  for  scrofulous 
bone  diseases  with  symptoms  of  rickets  a  mixture  of  lime-water 
and  other  substances,  for  example  :  — 

E  01.  jecoris  aselli 

Aqua  calcis     ...         aa  loo'o 

M.  f.  mist,  adde 

Tinct.  cinchoniE  co.   ...     2o'o  ]    or     Tinct.   aioes 

Tinct.  rhei  vinos        ...     is'o  r  Tinct.   ferri  pomat. 

Tinct.  calami  ...         ...       5*0)  Liq.  ammon.  anis.  6"o  to  jo'o 

M.D.S.     A    dessertspoonful    oi^   more,    once    to    three   times    a    daj'. 

The  addition  of  chocolate  (dragees)  does  not  fulfil  the  pur- 
pose, and  the  addition  of  rum,  spirit,  or  a  little  malaga  or  sherry 
after,  is  not  advisable,  as  alcohol  is  unnecessary  and  harmful  for 
children.  The  combination  of  cod-liver  oil  with  iodine  and  iron 
will  be  spoken  of  later. 

Cod-liver  oil  must  be  taken  for  a  long  time  and  always  shortly 
after  a  meal;  in  winter  it  can  be  taken  for  months;  still,  short 
pauses  are  to  be  recommended,  say,  every  two  or  three  weeks, 
when  a  pause  of  five  days  may  be  introduced ;  should  indigestion 
occur,    or   constant  eructation,    loss   of   appetite,    a   sick   feeling, 


I  III'KAI'I'.I,  I  ICS  325 

voiniLiiig    ()i-    (liairlid'ci,    (in    I  1m:    lallcr   case    tannalhin    should    \)t 
given),   iL  iniisl    hf;  disconlinncd   lor  some  liiru;. 

Morrhuol,  picqxired  by  ('iiaj)olcau  from  cod-liver  oil  and  said 
lo  contain  its  elTeclive  consLiluents  (a  capsule  of  o'2  -  5'o  cod- 
liver  oil)  is  used  l)ul  lililc  by  us. 

Where  there  is  very  great:  dislike  lo  cf)d-liver  oil  there  is  no 
necessity  to  insist  upon  it,  as  the  Lipanin  of  v.  Mering  (94  per 
cent.  oliv(;  oil,  6  per  cent,  fatly  acid),  though  certainly  .somewhat 
dearer,  has  an  agreeabUt  taste  and  is  at  the  same  time  an  easily 
assimilated  substiltile.  'J'he  dose  is  the  .same  as  that  of  cod-liver 
oil;  a  tablespoonful  is,  according  to  Klemperer,  e(jual  to  186 
calories.  vSesame  oil,  which  is  cheaper  than  cr)d-liver  oil  and 
is  easy  of  assimilation,  is  also  used. 

The  alcoholic  fcrmenlation  products  of  milk,  koumiss, 
yogurth,  kefir,  although  suitable  in  promoting  nutrition,  should 
only  be  ordered  for  children  in  cases  of  urgent  necessity,  as 
koumiss  contains  i'5  to  3  per  cent,  alcohol,  and  kefir  2'i  per  cent., 
the  child  would  get  in  500  grammes  the  same  quantity  of  alcohol 
(60  per  cent.)  as  in  a  small  glass  of  rum.  Kefir  of  one  day  old  con- 
tains less  alcohol  than  when  two  days  old,  and  still  less  than  when 
three  days  old.  In  kefir  prepared  from  milk  containing  tubercle 
bacilli,  the  bacilli  were  found  to  be  virulent  after  three  days  (am 
Sande). 

Of  preparations  of  carbohydrates,  besides  the  nutritive  meals 
and  legumens  already  spoken  of,  we  may  mention  malt  extract, 
which  children  enjoy  so  much  (Lof^und's  and  Brunnengraber's 
Maltocrystol,  Gehe's  Maltylkandol,  &c.).  A  teaspoonful  to  a 
tablespoonful  is  taken  three  times  a  day  (one  tablespoonful  = 
about  60  calories),  pure  or  combined  with  cod-liver  oil  and 
lipanin.  Other  valuable  aids  are  honey  (one  tablespoonful  = 
75  calories),  also  cocoa,  and  especially  the  Kraftschokolade 
(strengthening  chocolate)  of  v.  Mering  (with  the  addition  of  free 
fatty  acids),  Cassel  oat  cocoa,  Ovomaltine  (biscuits,  consisting 
of  malt  extract,  eggs,  milk  and  cocoa). 

Similar  preparations  are  Scott's  emulsion,  Ossin  Stroschein 
{Qgg  and  cod-liver  oil,  half  a  teaspoonful  to  a  tablespoonful  three 
times  a  day) ;  Ossogen  (hsematogen  and  cod-liver  oil) ;  Chocosana 
(a  preparation  of  cod-liver  oil  in  solid  form ;  cod-liver  oil,  cocoa 
and  sugar ;  for  children  under  4  years,  two  sticks ;  over  4.  three  or 
four  sticks;  or  a  teaspoonful  daily). 

As  substitutes  for  cod-liver  oil,  the  following  may  be  men- 
tioned :  Angier's  Emulsion  (petroleum  with  hvpophosphites) ; 
Fucol  (a  preparation  extracted  from  fresh  seaweed,  containing 
iodine  with  fatty  oils,  which  is  sold  mixed  with  iodide  of  iron, 
guaiacol,  or  malt  extract). 


326  SCROFULOSIS 

Tlie  neuropaihic  consiiiuiion  of  niaivy  scrofulous  persons 
explains  ihe  beneficial  efleci  of  preparations  of  phosphorus; 
Lecithin  (glycerine-phosphoric  acid,  the  higher  fatty  acids,  and 
cholin);  also  Lecithin  chocolate  and  "Lecithin  granule  Clin" 
are  all  verv  suitable  for  children  (one  teaspoonful -^- o'l  gramme 
lecithin,  but  lecithin  injections  are  not  to  be  employed  on  account 
of  being  painful) ;  Neocithin  (one  teaspoonful  to  a  tablespoonful 
several  times  daily) ;  Lecithol  (Ovo-Lecithin,  one  to  two  perles,  o'05 
gramme  in  each  ;  or  one  to  two  Lecithol  chocolate  tablets ;  or  in 
ampullcC  an  injection  every  oilier  day);  Protylin  Roche  (phos- 
phorus albumin),  one  to  two  teaspoonfuls  for  a  child  J  to  5  years 
old;  or  four  to  eight  tablets  for  a  child  5  to  12  years  old;  two  to 
three  teaspoonfuls,  or  eight  to  sixteen  tablets,  or  as  iron  protylin, 
containing  2\-^  per  cent,  or  iron);  Regenerin  (Ovo-Lecithin,  man- 
ganese and  iron,  one  teaspoonful  or  a  tablet  three  times  a  day) ; 
Phvlin  (prepared  from  the  seeds  of  plants  and  containing  22  per 
cent,  of  phosphorus);  Nucleogen,  Rosenberg  (nucleinic  acid  and 
iron  in  organic  combination  with  arsenic  and  phosphorus,  which 
is  much  liked,  one,  or  for  adults,  two  tablets,  0*05  gramme  in  each, 
three  times  a  day  after  meals,  either  subcutaneously  or  intra- 
muscularly in  sterilized  ampulla?,  containing  o'l  gramme,  daily  or 
every  other  dav  ;  for  children,  half  an  ampulla,  strongly  recom- 
mended bv  v.  Hoppe  and  others);  Leciferrin  (Ovo-Lecithin-Iron 
Schijtte,  half  a  tablespoonful  three  times  a  day). 

The  following  may  be  used  with  advantage  :  Fortosan  (a  pre- 
paration of  phytin  and  milk-sugar;  a  substitute  for  phosphorized 
cod-liver  oil,  two  or  four  measured  teaspoonfuls,  according  to 
age,  three  times  a  day) ;  Fellows's  Syrup  of  Hypophosphites  for 
adults,  two  teaspoonfuls  at  every  meal ;  for  children,  from  9  to 
12  years  of  age  half  the  amount,  from  5  to  9  years  of  age  a  third 
of  the  amount,  and  for  children  from  i  to  5  years  of  age  a  quarter 
of  the  adult  dose,  in  each  case  mixed  with  plenty  of  cold  water) ; 
and  Egger's  Hypophosphites  Syrup,  both  much  valued,  con- 
taining sulphate  of  quinine  and  strychnine  besides  hypophos- 
phoric  acid  combined  with  iron  and  manganese.  Then  the 
following  mav  be  mentioned  as  having  proved  of  value  in  pro- 
moting the  appetite  and  strengthening  :  Vial's  Tonic  Wine  (meat 
juice,  cinchona  bark,  calcium-lacto-phosphate,  with  Spanish 
wine) ;  cinchona  Serravallo,  with  iron  (highly  recommended  by 
Drasche) ;  Condurango  Cinchona  Elixir  Glaser  (with  or  without 
iron;  one  teaspoonful  to  one  tablespoonful  three  times  a  day); 
Manning's  Extract  of  Cinchona  (five  to  ten  drops  in  port  wine  or 
milk  three  times  a  day);  Dung's  Cinchona  Calisaya  Elixir  (one 
to  two  teaspoonfuls).  See  also  other  combinations  with  iron. 
P-  372- 


'nii:i</\i'KUTics  327 


OPEN-AIR  TREATMENT. 


On  the  lirsL  appcaraiu c  ot  iiiaiiilc.sl  .symptoms  oi  s(;rotuio.si.s 
a  profu.sion  of  air  and  liglil  is  an  imperative  demand,  the  only 
limit  with  respect  to  expcxsure  lo  liglii  being  certain  .symptoms 
of  disease,  e.g.,  conjunctivitis.  I'Or  a  child  already  affected  the 
general  recommendation  of  |)l(nl)  ol  fresh  air  is  emljraced  in  a 
systematic  open-air  line  of  irealment,  in  a  place  free  from  dust 
and  wind,  preferably  on  a  coninion,  and  in  all  weathers,  if  in  the 
least  suitable.  The  child  iiiusi  take  exercise  vvith(jut  much 
exertion,  unless  the  natiu'c  of  its  di.sease  {e.g.,  coxitis)  confines 
it  to  a  carriage  or  coucii.  An\'  increase  of  temperature  of  the 
body  forbids  exercise,  but  does  not  limit  the  open-air  treatment 
for  one  minute.  By  a  two-hourly  record  for  several  days  running 
one  finds  out  the  state  of  the  temperature. 

The  patient  must  be  spared  too  much  menial  exerti<jn,  school 
teaching  and  studies  must  be  reduced  within  suitable  bounds,  or 
must  be  given  up  entirely ;  but  one  must  consider  with  this 
whether  the  child  will  not  be  overexerted  and  more  injured  by 
making  up  for  lost  time  resulting  from  so  much  holiday  than 
by  continuing  to  go  to  school.  In  case  of  serious  illness  the  loss 
of  a  year's  schooling  (a  serious  sacrifice  for  ambitious  parents, 
but  a  point  on  which  the  doctor  must  insist)  is  richly  rewarded 
by  increased  health.  The  chief  object  is  to  act  radically  from  the 
very  beginning,  without  wasting  time  by  trying  mild  remedies, 
if  one  wishes  to  have  lasting  success. 

We  must  endeavour  to  place  children  whose  parents  have 
small  means  for  a  long  period  in  a  forest  recreation  place  or 
forest  school,  according  to  their  age  and  the  degree  of  their 
steength  (see  pp.  307-317). 

Where  patients  are  well-to-do  one  must  emphatically  insist, 
especially  when  the  improvement  at  home  is  unsatisfactory,  that 
the  child  shall  be  taken  to  a  place  with  a  favourable  climate,  ff 
it  be  difficult  to  find  the  necessary  person  to  accompanv  the  child 
for  some  time,  or  other  difficulties  present  themselves,  one  mav 
allow  the  alternative  of  sending  the  child  to  relations  in  the 
country  or  of  exchanging  homes  with  a  country  child,  provided 
that  other  demands  are  sufficiently  met.  Such  a  change  of 
environment,  of  climate  and  food,  has  a  stimulating  and  favour- 
able effect  mentally  and  phvsically. 

As  long  as  we  are  only  taking  preventive  measures  for 
debilitated  children,  or  if  for  some  cause  mineral  or  sea  baths 
are  not  indicated,  holiday  resorts  far  from  working  factories,  in  a 
position   sheltered  from   the  wind,   with   forest  or  mountain  air. 


328  •  SCROFULOSIS 

where  the  food  is  good,  render  vakiable  service.  li  is  incon- 
testible  that  children  with  sHght  scrofulous  sympionis  (eczema, 
&c.)  often  lose  these  sympioms  with  incredible  rapidity  only  by 
change  of  place,  a  stay  in  the  country  and  constant  fresh  air. 
But  where  we  have  to  do  wiih  manifest  scrofula,  a  severe  chronic 
illness  threatening  the  future  and  directly  dangerous  lo  life,  we 
must  not  content  ourselves  with  "  idyllic  country  life,"  but  must 
set  in  motion  the  whole  of  the  climatic  and  balneo-lherapeutic 
apparatus. 

The  wants  of  invalids  are,  unfortunately,  in  many  so-called 
health  resorts  not  sufficiently  taken  into  account.  The  demands 
of  Goldschmidt  and  others  to  make  the  right  of  using  the  title 
"  health  resort  "  like  thai  of  doctor,  subject  to  approval  by  the 
State  and  dependent  on  fullilling  certain  hygienic  postulates, 
deserves  more  serious  consideration  than  has  hitherto  been  given 
to  it.  The  more  renowned  health  resorts  have,  in  essential 
matters,  better  hvgienic  arrangements,  and,  especially  in  prophy- 
laxis against  tuberculosis  and  other  infectious  diseases,  offer 
more  security  than  any  other  places  one  may  name. 

It  is  an  inconsistency  met  with  in  doctors,  on  the  one  hand, 
to  emphasize  the  importance  of  hygiene  and  to  demand  a  good 
water  supply,  the  removal  of  refuse,  good  drainage,  healthy  dry 
houses,  control  of  food  supply  (examination  of  meat  and  milk), 
isolation  in  case  of  any  infectious  disease,  playgrounds  for  cliil- 
dren,  houses  with  spacious  balconies,  on  which  patients  may  lie, 
supervision  of  bathing  establishments,  and  hundreds  of  other 
things — in  short,  a  sanitary  superintendence — and  yet  not  send 
patients  who  have  the  means  to  do  all  that  is  necessary  for 
health  to  such  places  which  have  cost  hundreds  of  thousands,  and 
even  millions  of  marks,  in  order  to  be  able  to  satisfy  all  these 
demands,  but  to  content  themselves  with  a  simple  holiday  resort 
or  a  badly  arranged  health  resort,  because  "  that  will  perhaps  be 
sufficient  to  effect  an  improvement."  By  this  indolence  in  health 
resorts  is  encouraged  to  an  unwarrantable  extent,  and  the  task  of 
the  doctors  w4io  have  often  given  themselves  an  enormous  amount 
of  trouble  working  for  the  improvement  of  hygienic  conditions,  of 
itself  no  easy  matter,  is  rendered  even  more  difficult ;  the  patient 
is  badly  advised,  because,  besides  all  sorts  of  incidents  which 
may  arise,  the  things  that  he  most  needs  for  his  health  are  often 
wanting. 

Therefore,  in  the  interest  of  the  patient,  the  doctor  should 
acquaint  himself  exactly,  and  as  far  as  possible  personallv,  with 
these  conditions,  because  the  statements  made  by  the  authorities 
of  health  resorts  usually  paint  everything  in  glowing  colours. 


TIlKRAl'lilJ'lICS  329 

A.     CLIMATIC   HEALTH    RESORTS. 

i^urcly  cliinulic  lic;illli  icsoris  dIkti  ;i(Iiics<-  gooil  n-sulis  in 
quite  slight  cases,  and  in  ircalnicnl  allcr  mineral  and  sea  l^adis, 
or  wiien  llicse  are  conlra-indicalcd,  climatic  ir<'alnieiU  may  be 
talcen  into  consideration,  but  for  (lie  greater  part  of  scrofulous 
patients,  unless  we  wish  to  content  ourselves  with  piecemeal 
therapeutics,  we  recommend  llic  combination  of  the  treatment  by 
mineral  or  sea  baths  with  climatic  Ircalmcni. 

In  the  choice  of  climate  the  chief  i)oinl  to  keep  in  view  is  the 
l^ossibility  of  being  much  in  the  op(;n  air.  l'"or  special  cases  one 
must  remember  that  the  cold  air  draws  the  warmth  fnjm  the  body 
and  considerably  stimulates  metabolism,  but  also  favours  catarrh 
of  the  respiratory  passages  when  evaporation  is  promoted  by 
simultaneous  dryness  of  the  air.  Warm  and  dry  air  with  a  rela- 
tive moisture  of  under  60  per  cent,  with  plentiful  recreation, 
is  suitable  for  scrofulous  catarrh,  and  for  the  torpid  form  oi 
scrofulosis ;  warm  and  damp  air  (about  80  per  cent,  and  more) 
calms,  and  even  relaxes,  and  stimulates  metabolism  less,  but  has 
a  beneficial  influence  on  drv  catarrh  and  irritative  conditions  of 
the  mucous  membranes,  as  well  as  the  erethistic  form.  The  purity 
of  the  air  and  its  freedom  from  germs,  as  well  as  the  pressure, 
the  force  and  direction  of  the  wind,  the  content  of  ozone  and 
amount  of  sun,  must  be  taken  into  consideration. 

Inland  health  resorts  on  low-lving  ground,  or  heights  up  to 
400  metres  above  sea-level,  have  almost  an  indifferent  climate,  and 
therefore  onlv  a  slightly  stimulating  effect.  When  they  are  sur- 
rounded by  forests  or  shut  in  vallevs  the  climate  is  generally 
moist,  warm  and  uniform,  which  renders  them  suitable  for  sus- 
ceptible patients  with  no  power  of  resistance,  and  for  a  grear 
part  of  the  year  also  as  intermediate  stations,  and  especiallv  as 
winter  stations  when  in  southern  positions. 

The  places  in  a  sub-Alpine  climate  (400  to  950  metres)  with 
moderate  moisture  and  changes  of  temperature,  are  also  good  for 
susceptible,  weak,  excitable  natures ;  they  stimulate  the  nerves 
and  metabolism  in  a  higher  degree,  but  do  not  make  such  great 
demands  on  the  powers  of  resistance  as  mountain  or  sea  climates. 

The  so-called  high  mountain  ranges — heights  over  950  metres 
— with  their  attributes  of  pure  air,  rarefied  atmosphere  and  power- 
ful insolation,  stimulate  the  bodv  to  a  verv  high  degree.  Accord- 
ing to  the  researches  of  Zuntz,  A.  Loewv,  ]\Iiiller,  Caspari, 
and  others,  it  effects  an  increase  of  red  corpuscles,  which  reaches 
its  maximum  \vithin  two  or  three  weeks  and  onlv  sinks  again  on 
a  return  to  the  plains.     This  increase  reaches,  even   in   German 


330  SCROFULOSIS 

mouniains  ot  nu-cliuni  height,  to  i  lu  i^  millions  pvr  c.mm.  The 
high  mountain  climate  is  said  especially  to  stimulate  the  bone 
marrow. 

According  to  experiments  by  Biirker  on  the  Schatzalp,  and 
by  -Morawitz,  the  increase  of  red  corpuscles  is  not  so  great  as  is 
generally  believed,  and  amounts  at  medium  lieights  to .5  percent., 
and  that  of  the  haemoglobin  to  7  per  cent.  Schmincke  found  an 
increase  of  ervthrocytes  up  to  8  per  cent.  Durig  could  not  con- 
firm an  increase  either  of  blood  corpuscles  or  of  hiCMiioglobin. 

The  improvement  in  ajipeiile  owing  to  increased  metabolism, 
the  stimulation  of  the  activity  of  the  bowels,  and  the  influence 
on  the  respiration  is  incontestable  (see  also  Alb.  Robin).  On 
account  of  the  dry  air,  cool  even  in  summer,  and  the  changes  of 
temperature,  which  are  often  considerable,  the  climate  of  high 
mountains  presupposes  good  powers  of  resistance.  In  this 
respect  it  resembles  a  sea  climate  (in  spite  of  other  differences) 
bv  a  certain  meeting  of  extremes;  it  is  only  in  recent  years  that 
it  has  been  more  utilized  for  scrofulosis,  and  has,  according  to 
the  experience  of  Leysin,  sometimes  achieved  brilliant  successes 
in  bone  and  joint  tuberculosis  (see  p.  342).  High  mountain  air 
is  also  much  to  be  recommended  in  after  treatment,  when  the 
organism  has  become  more  resistant  owing  to  preceding  mineral 
bath  treatment,  and  in  man\'  cases  as  treatment  in  winter,  on 
account  of  plentiful  insolation  ;  mountain  air  is  contra-indicated 
in  \ery  auccmic,  nervous,  susceptible,  excitable,  scrofulous 
patients.  In  irritative  conditions  of  the  eyes,  the  great  intensity 
of  light  rays  have  often  unfaxourable  effects. 

The  climate  of  the  sea  and  coast  is  distinguished  by  its 
purity,  its  htunidity,  and  tlie  presence  of  salt,  by  its  frequent 
mo\-ement,  high  pressure,  and  relati\elv  regular  temperature  at 
different  seasons,  and  greater  brightness  owing  to  the  refraction 
of  the  surface  of  the  water.  It  has  a  powerful  effect  on  meta- 
bolism, and  is  excellent  for  torpid,  scrofulous  patients  who  need 
bracing;  but  for  debilitated  aucemic  patients,  or  erythistic  persons 
with  hypersensitive  mucous  membranes  it  is,  as  a  rule,  not 
indicated,  for  such  often  lose  their  sleep  and  appetite,  become 
depressed,  and  return  "  tanned  by  the  sun,  but  physically  weaker  " 
than  when  they  went  away.  Besides  which,  sea  and  coast 
climates  exhibit  great  differences  according  to  geographical 
position.  On  the  North  Sea  and  Atlantic  Ocean  these  climatic 
peculiarities  are  most  clearly  noticed,  but  the  Baltic  Sea,  the 
south  coast  of  England,  and  especially  the  Adriatic  and  the 
Mediterranean  Seas  are  far  milder,  and  therefore  may  be  recom- 
mended  with   good   prospect  of  success  for  more  weakly   natures 


■mi:KAi'i';ij'iK;s  331 

(;v(;n  (liinii(4  llic  \vinl<'i-  (sec  Dcicnii.i  11 11,  (inu-liii,  Moll  and 
Jlenig).  An  increase  ot  lia'ino^lohin  ,-iii<l  red  (  oipiisrles  lias  bef^i 
found  (llelwig)  lo  occdr  .-il  llie  se.-iside  jusi  ,-is  ii  does  in  mounlain 
air;  l)iil  Loewy,  in  (  oni  i;idi(  l  ion  lo  ilaljerlin,  (onid  noi  eonlirni 
a  permanent  incrense  in  die  loinl  (|n.-inlil\   o(  blood. 

vSea  vova<4'e.s,  as  reconnnended  hv  lleiin.'inn  W'ebe.r  in  so- 
called  ship  sanalori.-i  lor  die  phdiisicMl,  as  wdl  as  remaining  on 
the  open  sea  nenr  (lie  co.-isl  in  ships  arrnn^ed  for  llie  purpose, 
appear  lo  have  render<'d  good  ser\i((;  according"  to  pr(,'S(MU  experi- 
ence, though  this  has  hilherio  noi  been  very  extensive.  In  New 
York  a  steamer  daily  takes  1,000  to  1,500  children  to  the  open 
sea,  where  they  are  well  cared  for  (see  also  Natwig). 

B.— MINERAL  BATHS. 

Mineral  and  sea  baths,  as  well  as  salt  baths,  have  a  well- 
deserved  reputation  in  therapeutics  for  the  scrofulous;  they  are 
to  be  considered,  in  the  lirst  place,  when  change  of  climate  is 
thought  of.  Mineral  baths  have  the  one  distinct  advantage  over 
sea  baths,  that  the  stimulation  can  be  regidated,  suited  to  the 
strength  of  the  patient,  and  increased  according  to  necessity.  It 
has  long  been  noticed  that  by  such  baths,  not  only  the  body  in 
general  is  strengthened  often  to  a  remarkable  degree,  but  that 
with  a  sufficient  number  of  baths  local  affections,  and  even  large 
glandular  tumours,  return  to  a  normal  size,  white  swelling  dis- 
appears, tistuke  close,  open  foci  form  healths"  granulations,  and 
this  improvement  appears  considerably  sooner  and  more  fully 
than  under  change  of  climate  alone.  Therefore,  when  change  of 
climate  is  contemplated,  places  with  mineral  and  sea  baths  should 
be  preferred  as  a  rule. 

Effect. — Even  in  a  fresh-water  bath  more  resistance  is 
opposed  to  the  breathing,  the  muscular  movements,  and  the 
circulation  on  account  of  the  pressure  of  the  water  on  the  body 
than  by  the  air  alone,  a  certain  stimulus  is  produced,  and  this 
mechanical  stimulus  is  slightly  increased  in  a  mineral  bath  owing 
to  the  greater  specific  gravity  of  the  salt  water,  the  thermic 
stimulus  is  also  increased  because  the  mineral  bath  is  given  some- 
what cooler  below  the  natural  temperature  of  the  bodv.  But  the 
chief  effect  is  explained  by  the  fact  that  the  chlorides  are  not, 
as  formerly  stated,  absorbed  and  taken  up  by  the  blood,  but 
permeate  the  epidermis,  and  there  cause  exosmosis  of  the  fluids 
of  the  tissues,  and  by  this  a  stimijlation  of  the  branches  of  the 
terminal  nerves  in  the  cutis.  This  mav  be  often  fell  subjectivelv, 
and  may  be  objectively  proved  by  a  measure  of  the  increased 
sensibility  (Clemens,  Santlus  and  Beneke). 


^1,2  SCROFULOSIS 

The  mineral  bath  has,  ilierefore,  ihis  advantage  over  the 
Drdinary  bath  :  that  the  necessary  stimulus  is  given  with  a  lower 
temperature  of  the  skin  (Braun)  and  by  the  increased  stimulus 
which  it  causes,  the  feeling  of  coldness,  resulting  from  a  baih 
under  the  normal  temperature  of  the  body,  is  lessened,  and  thus 
a  cooler  temperature  is  possible  for  a  longer  lime  (Senator). 

Opinions  as  to  the  effect  of  these  baths  in  detail  are  very 
varied.  The  energy  of  metabolism  is  increased  by  reflex  action, 
pathological  products  are  absorbed,  the  excretion  of  carbonic  acid, 
according  to  Rolirig  and  Zuntz,  and  of  urea,  according  to  L. 
Lehmann  and  Beneke,  is  increased,  whereas  that  of  uric  and 
phosphoric  acids  is  reduced.^  According  to  Robin  and  Heubner 
(two  experiments  made  with  Langstein  and  Rietschel)  the  excre- 
tion of  nitrogen  is  increased;  a  retention  of  chlorides,  as  Keller 
(Rheinfelden)  had  stated  to  be  the  case  under  the  influence  of 
mineral  baths,  could  not  be  confirmed  by  Heubner.  As  a  result 
of  increased  appetite  and  food  with  assimilation  and  growth  the 
weight  of  the  body  is  improved. 

Manv  authors  (Wimmer  and  Kanzler)  attribute  higher 
stimulative  properties  to  chloride  of  lime  and  chloride  of 
magnesia  (as  being  highly  hygroscopic  bodies)  than  to  chloride 
of  potash  and  to  chloride  of  soda,  and  based  the  stronger  action 
on  their  specially  abundant  mother  lye.  According  to  Clemens 
and  Neubauer,  solutions  of  sulphates,  iodide  of  potassium,  and 
Glauber  salts  are  entirely  lacking  in  such  action.  According  ij 
E.  Lehmann,  the  evidence  of  the  adhesion  to  the  skin  of  the  salts 
contained  in  the  l:»alii,  both  during  and  even  after  the  bath, 
explains  the  itching  and  smarting  of  the  skin,  and  the  sensation 
of  shivering  and  the  formation  of  boils  after  taking  strong  mineral 
baths  for  some  time. 

The  value  of  iodine  and  bromine  combinations  in  the  mineral 
water  of  the  baths,  formerly  so  highly  prized,  has  not  been  clearly 
shown  ;  still  a  certain  influence  is  not  to  be  denied,  perhaps  by 
respiration  of  the  exhalations  from  these  minerals.  For  the 
amounts  of  iodine  and  bromine  in  the  drinking  mineral  waters, 
see  below. 

The  carbonic  acid  contents  of  many  mineral  springs 
strengthens  the  action  by  the  increased  stimulus  exercised  on 
the  nerves  of  the  skin  ;  this  is  shown — cceteris  paribus — by  an 
increased  feeling  of  w-armth  and  of  redness  of  the  skin,  even  after 
the  bath,  and  allows  of  a  further  reduction  of  the  temperature  of 
the  bath  below  the  temperature  of  the  body  down  to  29°  C,  even 

'  According  to  Keller  a  mineral  3  per  cent,  bath  is  followed  by  a 
greater  increase  of  chlorides  in  the  urine  than  a  6  per  cent,  mineral  bath. 


■|jiKi<Ai'i':i;ii(:s  t,:^:] 

U)  27°  ('.  (24°-22'^  k.j,  wiilioiii  c'liisin^  ;i  disagreeable  feeling  of 
coldness.  In  some  Im-.-iIiIi  rcsorls  arr.-ingcuicnls  arr  made  for  iIk- 
artificial  addition  ol  carbonic  acid  (o  tiic  mineral  ballis.  llie 
rather  complicalcd  nielliods  of  Dr.  Raydi,  Kiefer,  and  especially 
that  of  Keller  (saturaling  I  Ik;  water  or  evaporated  water  witli 
CO3  under  liigh  pr(;ssure),  vvliicli  are  only  suitable  for  large  batli- 
ing  establishments,  satisfy  all  r((|iiiicmcni.s  according  Ifj  my 
experience,  at  least  in  Keichenhall.  Senator  praises  ]5l(x;h's 
method,  the  simple  method  of  production  by  Sandow  (the  addition 
of  bicarbonate  of  sodiimi  and  bisulphate  of  sodium)  and  that  of 
Quagiio;  bicarbonate  of  sodium  and  hydrochloric  acid  ar^  very 
poor  substitutes,  and  can  onl\-  be  used  at  homf  ;  Zurker's  mflhod 
is  belter. 

The  addition  of  cxlract  of  pine  needles  to  the  bath  is  ver\- 
suitable. 

We  await  further  I'esearches  as  lo  how  far  the  therapeutic 
effect  of  the  radio-activity  of  mineral  baths  is  useful  and  has 
predominating  influence. 

INDICATION. 

Mineral  baths  are  in  general  indicated  for  patients  suffering 
from  all  forms  of  scrofulosis,  except  in  very  early  childhood,  or 
in  conditions  of  great  weakness  or  fever.  Phlegmatic  cliildren 
who  need  powerful  stimulation  are  given  highly  concentrated 
mineral  baths  of  long  duration ;  for  weak,  susceptible,  irritable, 
excitable  children  they  must  be  weaker  and  shorter.  When  anv 
affection  of  the  ears  is  present  mineral  baths,  and,  indeed,  all 
forms  of  baths,  require  special  care. 

We  must  bear  in  mind  that  if  they  are  not  to  be  harmful, 
being  a  different  remedy  from  what  the  patient  is  used  to,  thev 
require  to  be  exactly  regulated  as  to  strength,  temperature,  length, 
number  and  sequence,  and  they  require  also  careful  watching  of 
the  effect  by  a  weekly  control  of  the  weight  of  the  child.  Mineral 
baths  act  on  different  people  in  a  different  manner ;  an  apparentlv 
strong  man  will  often  be  greatly  prostrated  by  a  bath  of  medium 
strength,  whilst  sometimes  delicate  children  and  women  feel 
wonderfully  well  after  the  strongest  mineral  bath  ;  therefore,  with 
even  great  practical  experience,  it  is  not  always  possible  to  deter- 
mine how  the  mineral  bath  will  suit  the  patient,  and  often  in  the 
course  of  treatment  it  is  necessary  to  alter  the  regulations. 

Patients  will  often  receive  detailed  regulations  from  the 
family  physician  for  weeks  in  advance  respecting  the  use  of 
mineral  and  sea  baths,  and  do  themselves  harm  either  bv  taking 
too  many  or  not  enough,  and  so  in  this  case  depriving  themselves 


334  SCROFLLOSIS 

of  ihe  full  elYect  of  the  Ireatnieni.  Alihough  iltc  family  physician 
is  best  capable  of  achising  because  he  kn(»\\s  ilie  jjaiienl  and  his 
constitulion  best,  he  nuisl  use  a  ceiiain  reser\  e,  lesi  he  be  maele 
responsible  in  casr  of  non-succr.ss.  I'\ii"  inxaliils  who  so  trecjuenth' 
lake  the  balhs  on  ihrir  own  auihoriu-  ilu-  axiom  volciiii  non  fit 
injuria — is  apj)ro])riaii'. 

Over-slinuilaiion  from  mineral  balhs  generally  shows  itself 
by  great  lassiiude,  coniinuing  even  beyond  the  time  of  rest  after 
the  bath,  by  a  feeling  of  weakness,  restless  sleep  wilh  disturbed 
dreams,  loss  of  ai^peiiu-,  cxcilabiliu',  a  morose,  irritable  slate  of 
mind,  b\-  whims,  lits  of  crying,  rudeness,  and — after  a  long- 
coniinucd  (i\  t-r-siimulaiion — e\(Mi  h}-  ra])id  pulse,  feverish  attacks, 
and  loss  of  weigh i.  In  case  of  sucli  disturbances  the  baths  must 
be  at  once  disconiinued  for  a  few  davs,  or  even  longer,  if  the 
treatment  is  to  be  successful,  and  an-  onlx  lo  be  renewed  later  in 
reduced  strength  for  a  shorter  time,  and  less  frequentl}  . 

Such  want  of  success  of  mineral  balhs  in  the  scrofulous  is 
almost  enlire]\-  caused  b\"  inappropriate  apportioning  of  the 
strenglh  of  ihe  consliluenls,  and  scldoni  1)\-  being  contra- 
indicated. 

But,  on  the  other  hand,  too  weak  balhs  from  o\er-caution  are 
a  failure.  The  principle  must  be  to  give  as  many  balhs  and  as 
strong  as  possible  suitable  to  the  patient  ;  for  this  there  must  be 
constant  and  attentive  superintendence  by  a  doctor. 

Carbonic  acid  baths  are  often  accompanied  by  oppression, 
a  dazed  feeling,  headache,  giddiness,  buzzing  in  the  ears,  palpi- 
tation, even  a  condition  similar  to  intoxication.  These  symptoms 
are  caused  by  inhaling'  the  carbonic  acid  released  from  the  water, 
and  may  be  avoided  by  keeping  the  acid  from  the  respiratory 
passages  by  means  of  a  frame  of  wood  laid  on  the  bath  and 
covered  with  oilcloth,  and  liaving  a  hole  for  the  head  to  pass 
through.  If  the  disturbances  continue,  in  case  of  palpitation  and 
so  on,  it  may  be  necessary,  especially  with  very  sensitive  children, 
to  have  recourse  to  mineral  balhs  with  free  CO.,. 

MODE  OF  USE. 

The  intensity  of  the  effect  of  mineral  baths  depends  on  the 
individual  as  w-ell  as  upon  the  mode  of  use,  the  strenglh,  tem- 
perature, length,  frequency  and  number. 

The  morning  is  the  best  time  for  the  baths,  about  an  hour 
after  a  light  breakfast.  They  do  not  suit  weakly  persons  when 
fasting,  and  cause  headache,  paleness,  &c.,  neither  may  they 
be  taken  on  a  full  stomach  ;  therefore,  if  taken  during  the  after- 


TllKKAPKIJIICS  335 

noon,    al    Icasl    iliif(t    or   tour    hours'    iiii<M\al    after    ilx-    iiH-al    is 
rrcjuiicd. 

The  slrciiglli  ol   ihc  niiurral  Wnlhs      \\\r  auiounl  ol  (hloridfs- 
niusl    1)(^  arranged  accordinj^    lo   ihc   vi^niur  and   suscfpi  iWiliiy   of 
the  i)ali<'nl .      (  )n  .-iii  a\'cra<4C 

Children  of  i  year  arc  given  J-ii  per  cent,  mineral  baths 
,,  2-4  years  and  delicate  children       1-2  per  cent. 

,,  5-10  years   ...         ...         ...         ...      1-4  •• 

Torpid    ;n-id    older   children    ;ind    ;ifliills        ...      ^-<' 

In  exceptional   ca.se.s  S-io  |)<-r  (cni.   is  icachcd,   and  recently 
a  few  up  to  12  per  cent,  and  o\er  have  been  given  (see  Kt'ithy- 
with  phlegmatic  children — 9  per  cent.). 

As  a  rule  mineral  badis  from  o'5  lo  2  [x-r  cent,  are  .styled 
weak,  from  2-4  j^er  cent,  mediimi,  from  4-6  per  cent,  strong. 

I  have  found  it  best  to  begin  with  \ery  weak  balhs  and 
gradually  to  increase  the  strength;  in  this  manner  much  stronger 
baths  are  borne  much  belter  later  than  if  one  ordered  a  certain 
percentage  at  once,  even  if  il  were  of  moderate  degree. 

The  concentration  of  natural  .salt  and  mineral  springs  \arie5 
within  very  wide  limits  .from  0*5  to  30  per  cent. ;  those  imder 
I "5  per  cent,  are  generally  termed  salt  springs;  the  stronger, 
mineral  springs.  We  distinguish  further,  cold  and  warm 
springs,  simple  springs,  those  containing  iodine  or  bromine,  and 
lastly  carbonic  acid  springs. 

The  weaker  springs  are,  in  the  case  of  scrofuUius  patients, 
often  onlv  used  in  drinking ;  when  used  for  bathing,  to  get  the 
necessarv  degree  of  concentration  for  stronger  or  phlegmatic 
persons,  a  condensation  or  addition  of  mother-lye^  is  needful, 
w^hich  adds  very  little  to  the  expense,  but  may  lead  to  a  decrease 
of  the  desired  strength,  and  even  to  falsification  in  bathing 
establishments  which  are  not  properly  superintended. 

Strong  mineral  springs  have  the  advantage  of  easilv  giving 
any  degree  of  concentration  desired  by  the  addition  of  water; 
there  are  no  other  reasons  which  make  them  less  desirable  than 
weak  springs. 

The  temperature  of  the  mineral  baths  is  regulated  in  the  first 
place  according  to  the  individual ;  for  the  ana?mic,  33°-33'-*  C.  is 
used,  otherwise  3i°-32°  C. ;  for  the  strong,  who  rapidlv  replace 
lost  w^armth,  3i°-30°  C. ;  the  temperature  rnav  be  reduced  within 
these  limits  according  to  the  increase  in  mineral  strength. 

^  Mother-lye  is  the  mineral  deposit  which  remains  as  a  very  concen- 
trated solution  of  chloride  of  lime,  chloride  of  magnesium,  and  chloride  of 
potash,  &c.,  after  heating  common  salt. 


oo 


6  SCROFULOSIS 


Mineral  baths  ('(Miiainiiig  carl)t)nic  acitl  are  generally  given 
at   :,2°-2Cf-2'J^  C. 

The  cluralion  ot  each  balh  is  also  regiilalecl  according  to 
individual  constilulii)n,  and  a  gradual  advance  and  habilualion 
are  most  suitable.  We  begin,  as  a  rule,  with  five  or  ten  minutes, 
rising  to  twenty,  thirty,  and  even  foriy-ll\  t'  minutes.  The  shorter 
baths  serve  for  exciting  metabolism ;  the  longer  and  warmer  ones 
for  absorption. 

After  the  bath  a  cool,  or  even  cold,  shower  bath  or  douche  is 
advisable  according  to  the  nature  of  the  case,  after  which  the 
patient  must  rest  from  half  to  one  hour,  best  in  bed,  but  at  least 
with  loose  clothing  (without  corsets  !  !),  otherwise  there  will  be 
headache,  loss  of  sleep  and  appetite ;  delicate  persons  may  take 
a  glass  of  milk  or  wine  or  a  little  bread  and  butter.  When  the 
bathing  establishments  are  far  from  the  house  which  the  patient 
occupies,  as  in  many  health  resorts  is  unfortunately  the  case,  and 
opportunity  for  rest  is  not  offered  in  the  establishment  itself,  some 
cooling  process  is  all  the  more  necessary  for  susceptible  persons 
to  avoid  taking  cold.  Exercise  in  the  open  air  after  a  bath  is 
only  to  be  allowed  for  very  strong  persons  in  good  weather;  studv 
or  letter-writing  at  this  time  is  injudicious. 

The  frequency  of  the  baths  is  determined  by  the  result. 
With  delicate  children  the  baths  may  be  given  every  three  days, 
with  others  every  other  day;  strong  persons  take  them,  if  they 
suit,  every  day,  or  leave  out  every  third  or  fifth  day.  A  doctor 
must  not  allow  himself  to  be  influenced  by  the  importunity  of  the 
patient,  but  only  by  the  effect  of  the  baths.  With  rapid  increase 
in  weight  one  can  advance  more  quickly  to  stronger  baths;  with 
many  patients  this  increase  only  takes  place  after  the  end  of  the 
baths,  during  the  after-treatment. 

The  total  number  of  baths  for  very  young  children  is  fifteen 
to  twenty,  for  older  children  thirty  to  forty,  seldom  fifty,  A 
certain  difficulty  arises  from  the  mistaken  idea  that  the  patient 
must  take  a  fixed  number.  In  reality  the  number  is  unimportant ; 
the  result  is  to  be  the  chief  guide.  On  the  other  hand,  the 
maximum  number  has  been  arrived  at  from  the  usual  length  of 
the  treatment  based  on  other  reasons,  and  as  long  as  the  baths 
suit  the  patient  there  is  no  reason  why  this  maximum  should  not 
be  surpassed. 

The  total  length  of  the  bath  treatment  is  about  six  to  nine 
weeks  (for  the  length  of  the  climatic  treatment,  see  pp.  167,  329 
and  343). 

Mineral  baths  may  be  taken  at  any  time  during  the  year. 
Bathing  resorts  are  mostly  open  from  the  beginning  of  May  to 
the  end  of  October. 


IIIICUAl'KUTICS  337 

F(n"  lasliiif^  success  in  ili<-  1 1  i;ii  iiicni  <,\  s(  idI  ulosis  (wiili  llie 
exception  ot  lln;  very  sligliicsl  cascsj  llic  miiinal  hailis  rnusl 
be  repeated  two  or  tliree  tim(;s  in  consecutive-  years,  and  ii  is  well 
to  draw  the  attention  of  parents  lo  iliis  fact  at  once.  'llie  re- 
petition in  the  same  year  (spring  and  autuninj  1  have  generally 
found  lo  be  less  advisable;  an  immediate  reiurn  home,  and 
especially  a  return  to  school,  ina)  olien  endanger  tlie  whole  success 
of  the  treatment,  as  according  to  experience  this  is  followed  for 
a  long  period  by  a  condition  of  hypersensitiveness,  and  often  the 
full  effect  is  only  developed  later;  if  in  any  way  possible,  a  rest 
of  from  two  to  live  weeks  in  the  same  place,  or  one  climatically 
somewhat  different,  is  to  be  recommended.  When  the  mineral 
baths  have  had  good  effect  and  there  has  been  considerable  gain 
of  strength,  such  places  are  the  most  suitable  which  make 
increased  demands  on  the  physical  powers  rather  than  places  in 
higher  altitudes,  or  by  the  sea  (unless  further  sea  baths  be  taken). 

To  prevent  misconception  about  the  total  length  of  such  a 
treatment  till  complete  recovery  is  obtained,  refer  to  the  results 
communicated  below  in  mineral  and  sea  bathing  stations  (see 
p.  361). 

C— SEA  BATHS. 

Hippocrates  advised  washing  with  sea  water  for  those  qui 
ab  acribus  humoribus  ardentur.  The  founder  of  modern  Thalasso- 
therapeutics  may  be  considered  to  be  the  English  doctor,  Russel, 
who  in  1750  recommended  them  in  his  book  "  De  tabe  glandulari 
sive  de  usu  aqu^  marin^e  in  morbit  glandularum."  Sea  baths, 
in  conjunction  with  mineral  baths,  have  achieved  an  important 
position  in  the  therapeutics  of  scrofulosis. 

EFFECT. 

In  sea  baths,  besides  the  effect  of  the  salt,  which  is  un- 
important owing  to  the  short  duration  of  the  bath,  the  cooler 
temperature  acts  as  a  powerful  thermic  stimulus ;  the  great  loss 
of  warmth  of  the  body  consequent  on  the  baths  is  only  felt  bv 
the  bathers  in  the  first  few  moments,  it  is  then  covered  by  the 
great  mechanical  reaction  caused  by  the  exertion  required  to 
withstand  the  beating  of  the  waves,  and  the  pressure  and  friction 
which  the  mass  of  water  exerts  on  the  body.  The  powerful  reflex 
stimulation  of  metabolism  is  shown  by  a  great  increase  of  urine 
and  reduction  of  uric  and  phosphoric  acid  in  the  urine,  and  is 
visible  in  keener  appetite  and  increased  weight.  The  frequencv 
of   the    pulse    is   increased,    and    transitorilv   the    svstolic    blood- 

22 


23^  SCROFL  LOSIS 

pressure  is  heightened  (Loewy).     A  number  of  works  on  the  effect 
of  sea  baths  Iiave  been  pubHslu'el  in  n-ct-nt  years  (see  Hiiberlin). 

INDICATION. 

As  an  energetic  means  (ov  j^romoiing  active  metabolism,  the 
indication  for  sea  baths  is  tlie  same  as  that  of  sea  cHmate  and  sea 
air,  discussed  above.  They  are  most  excellent  for  phlegmatic, 
fairly  robust  constitutions  which  are  able  to  withstand  strong 
impulses;  they  have  proved  themselves  unsuitable  for  weak,  very 
anaemic,  thin,  excitable  individuals  who  are  unable  to  compen- 
sate for  increased  loss  of  material  by  taking  an  extra  amount  of 
nourishment,  and  by  further  assimilation  to  prevent  bodily  bank- 
ruptcy, and  for  persons  who  suffer  from  a  nervous  and  obstinate 
irritant  cough.  With  weakly  patients  sea  baths  may  only  be 
cautiously  tried  in  their  very  mildest  form,  in  the  Mediterranean 
and  Baltic  Seas  (pregnant  women  should  only  bathe  in  the  sea 
up  to  the  sixth  month)  as  a  rule.  In  doubtful  cases  mineral  baths 
are  preferable. 

Sea  baths  are  contra-indicated  for  children  up  to  i  year  old, 
especially  as  their  fear  at  the  sight  of  the  sea  is  a  hindrance;  as 
they  grow  older  they  may  be  gradually  accustomed  to  cool  baths 
by  sponging  them  down  with  sea  water  and  by  warm  sea  baths 
(in  its  effect  the  same  as  mineral  baths). 

In  scrofulous  ear  diseases,  as  in  any  other  affection  of  the 
ears,  sea  baths  are  contra-indicated. 

As  signs  that  sea  baths  are  unsuitable,  or  that  over-stimulation 
has  taken  place,  loss  of  appetite  and  loss  of  sleep  occur,  as  in  the 
case  of  mineral  baths;  chilliness  and  shivering  in  the  bath, 
excitability,  paleness,  prostration,  considerable  loss  of  weight  are 
a  warning  to  discontinue  the  treatment,  and  either  to  take  to  warm 
baths  or  even  to  change  to  a  less  exhilarating  climate. 

Some  disadvantages  which  sea  baths  have  over  mineral  baths 
are  that  the  amount  of  salt  cannot  be  arranged  to  suit  individual 
needs  (the  North  Sea  contains  about  3  per  cent,  salt),  also  the 
motion  of  the  waves  and  the  temperature  are  not  under  our  con- 
trol, and  the  use  of  these  baths  depends  very  much  upon  the 
weather. 

MODE  OF  USE. 

The  mode  of  use  is  in  certain  respects  different  from  that  of 
mineral  baths.  With  weakly  persons  they  must  only  be  begun 
in  very  warm  weather.     The  bath   is  best  taken  at  high  tide,  if 


'jiii:kai>i;i;')ic.s  339 

possible  bclore  n(j(jii,  and  never  fasling;  delicaie  jjf;rsons  ma)/ 
take  a  glass  oi  warm  milk,  (  (k  n,i,  or  wine  or  brandy  beforeiiand. 

TIk;  duration  is  acccjrding  io  ilie  powers  of  die  individual.  Ai 
iirsl,  tor  scrolulous  patients,  only  a  moment  or  ball  a  minute,  iben 
one  to  livt;  minutes,  seldom  more.  At  lierc-sur-mer  ten  minutes 
is  rarely  allowed.  In  any  case  llie  bath  must  cease  be-fore  the 
feeling  of  warmili  lias  given  way  to  shivering. 

The  sea  bath  is  to  be  followed  by  a  walk  and  a  meal. 

We  often  observe  a  loss  of  weight  during  the  bathing  pe-riod, 
and  considerable;  increase  after  the  batiis  have  ceased. 

The  frequency  and  l<jlal  number  of  baths  is  arranged 
according  to  their  effect  and  the  strength  of  the  patient,  partly 
also  according  to  local  circumstances.  At  Berc-sur-mer,  for 
example,  scrofuknis  children  bathe  almost  daily;  in  German 
stations  (according  to  Brauer)  they  seldom  bathe  daily,  generally 
two  or  four  times  weekly.  The  total  number  of  baths  in  the 
North  Sea  bathing  places  is  fifteen  to  twenty  for  women,  twenty 
to  twenty-live  for  men,  fewer  for  delicate  persons,  whilst,  accord- 
ing to  Brauer,  in  vSestri  the  children  take  on  an  average  sixty-five 
baths. 

The  season  for  bathing  varies  greatly  according  to  the 
geographical  position  of  the  place,  and  the  more  northerly  the 
situation  the  more  it  is  limited  to  the  hottest  months.  Whilst  in 
the  Mediterranean  bathing  is  carried  on  until  late  in  the  autumn, 
and  for  delicate  persons  a  stay  there  during  the  whole  winter  is 
suitable,  in  the  German  North  Sea  one  can  only  bathe  from  the 
beginning  of  July  until  the  end  of  September.  In  order  to  some- 
what extend  this  sliort  time,  and  to  be  independent  of  weather 
and  seasons,  and  to  find  a  substitute  for  weaker  persons  whom 
cold  sea  baths  do  not  suit,  in  many  places,  especially  northern 
ones,  warm  sea  baths  have  been  established,  which  naturally 
differ  in  no  way  from  a  mineral  bath  with  a  fixed  concentration 
of  salt. 

These,  as  well  as  sponging  with  sea  water,  are  used  for 
•delicate  persons  as  a  transition  to  cold  baths.  In  some  places — at 
Norderney,  for  example — in  this  manner  a  complete  winter  course 
of  treatment  has  been  arranged. 

D.— SULPHUR  AND  ARSENIC  SPRINGS. 

Sulphur  springs,  the  action  of  which  needs  a  better  scientitic 
foundation,  have  in  many  cases  proved  themselyes  empirically 
of  yalue  for  scrofulous  patients,  and  are  much  prized  in  France, 


340  SCROFULOSIS 

where  there  are  many  sulphur  springs,  especially  in  the  Pyrenees. 
The  baths  are  taken  for  scrofulous  skin  diseases,  in  scrofulous 
catarrh  of  the  respiratory  passages,  and  to  promote  digestion. 
Suliiluir  springs — for  example,  those  of  Weilbach — are  used 
internal ly.     The  same  may  be  said  of  arsenic  springs. 

E.— AUXILIARIES  TO  MINERAL  AND  SEA-BATHING 
TREATMENT. 

Besides  the  baths,  certain  climatic  and  balneo-therapeutic 
auxiliary  remedies  for  scrofulosis  may  be  taken  into  account. 

In  the  choice  of  a  watering-place,  the  presence  of  a 
"  graduating  house  "   is  often  considered. 

A  graduating  house  is  a  long  scaffolding  of  beams  filled  up 
with  bundles  of  twigs,  from  which  the  mineral  water  falls,  drop 
by  drop,  from  twig  to  twig,  and  is  partly  evaporated  and  thus 
concentrated  (graduated). 

The  air  in  such  graduating  works  is  cool,  very  damp,  im- 
pregnated with  particles  of  salt,  often  smells  of  bromine,  and  is 
rich  in  ozone,  which  is  liberated  by  the  evaporation  of  salt  water 
(as  at  the  seaside).  It  thus  in  many  ways  resembles  sea  air,  but 
there  is  no  great  motion  in  the  air,  as  the  graduating  fences  afford 
protection  from   it. 

A  stay  there  is  very  agreeable,  especially  on  hot  days ;  it 
provides  the  advantages  of  abundant  inhalation,  and  has  a 
beneficial  effect  on  irritative  conditions  and  dry  catarrh  of  the 
scrofulous,  but  possesses  no  specific  qualities.  A  visit  to  these 
houses  demands  certain  precautions  on  account  of  the  consider- 
able difference  of  temperature  (4-8°  C.)  in  them  from  their  sur- 
roundings, especially  on  warm  days,  the  neglect  of  which  must 
often  be  dearly  paid  for  by  those  not  acquainted  with  the  existing 
conditions  (see  Locher,  Krone). 

The  water-drinking  treatment  arranged  in  most  watering- 
places  is  used  with  advantage  by  many  scrofulous  patients,  and 
may  be  discussed  here,  although  belonging  to  internal  treat- 
ment. Weaker  mineral  springs  containing  r5  per  cent,  of  solid 
matter  are  drunk  pure,  the  stronger  are  diluted  proportionately; 
imported  mineral  waters  are  also  much  used. 

The  scientific  explanation  of  the  action  is  not  quite  satis- 
factory, and  needs  further  discussion.  Langstein  and  Ritschel 
have  not  been  able  to  demonstrate  any  alteration  in  the  amount 
of   nitrogen,   chlorine  and   phosphorus  from    internal  use   of  the 


TJIKRAI'Ktri  ICS  341 

mineral   waters  (lor  ilic  ((inir.irv  view,   S(;(;  p.  331;.      lMi)|)irieall\', 
the  benelil    is  (|iiilf  cslablislicd  (s^r   K.   \\'c\^i-y\). 

The  coinnion  sail  springs  ar(,'  (;rder(;d  lor  (lie  seroliilous  -is 
the  water  removes  dyspejosia,  facilitates  tlu;  action  of  iIh;  bowels, 
and  furtliei"s  nudabolisni,  digcsiion  and  nniiiiion,  and  in  catarrh 
of  the  )-esj)ira(ory  passages  loosens  the  secretions  b\-  rcnderin^^ 
them  fluid. 

The  numerous  cold  s;di  springs  ri(  h  in  carbonic  acid,  even 
when  the  amount  of  salt  is  small,  ex(^rl  a  fxnverful  stimulus  on 
the  mucous  membrane  of  the  stomach  by  means  of  their  carbonic 
acid  and  cool  temi)eralure ;  a  warm  temperature  weakens  the  direct 
effect  of  the  salt,  hastens  its  absorption,  and  thus  acts  more 
energetically  on  the  blood  (Braun). 

Stronger  salt  springs,  free  from  carbonic  acid,  are  often 
artificially  mixed  with  CO^,  or  drunk-  diluted  with  carbonic  acid 
waters  (carbonated  waters). 

Braun  preferred  the  Carlsbad  waters  to  the  allied  salt  springs, 
which  often  induce  catarrh  of  the  intestinal  mucous  membrane; 
Kanzler  also  speaks  in  favour  of  Carlsbad  salts  in  scrofulous 
patients  suffering  from  catarrh  of  the  stomach  and  duodenum, 
chronic  constipation,  and  intestinal  inertia,  with  absorption  of 
pathological  products. 

By  some  the  iodine  and  bromine  contents  of  different  salt 
springs  is  much  valued  ;^  indeed,  the  chief  effect  is  attributed  to 
it.  But  whatever  value  may  be  attached  to  the  use  of  iodine  in 
many  forms  of  scrofulosis,  especially  in  glandular  affections  in 
well-nourished  older  children,  the  quantity  of  iodine  and  bromide 
contained  in  the  ordinary  mineral  waters  is  so  small  in  compari- 
son with  the  pharmaceutical  dose  necessary  to  produce  any  effect 
worth  mentioning  that  a  result  could  only  be  effected  bv  using 
them  for  a  length  of  time.  The  common  salt  waters  of  Kreuz- 
nach  (Elizabeth  Spring),  Hall  (Thassilo  Spring),  and  Heilbrun 
(Adelheid  Spring),  containing  iodine  are  in  severe  cases  of  scrofu- 
losis to  be  classed  with  the  ordinary  salt  springs  for  internal  use. 

The  chalybeate  waters  of  Pyrmont,  Schwalbach  and  Spa 
have  been  used  with  good  effects  in  cases  of  scrofulosis,  combined 
with  true  anaemia;  mere  paleness  is  no  guide  on  this  point  (see 

P-54)- 

Sea  water  is  also  given  internally,  but  if  unfiltered  it  readilv 
causes    diarrhoea.      Dalton    recommended    ^   to    i^    litres    dailv. 

'  It  has   also  been   stated   that   the   combination   of   iodine   in    different 
salts  renders  them  more  easily  absorbed. 


342  SCROFULOSIS 

Robert  Simon  and  Rene  Ouinion  injected  sea  water,  made  isotonic 
to  the  fluids  of  the  tissues,  subculaneously  every  three  or  four 
days,  100-300  grammes  for  sixty  days,  and  mention  satisfactory 
resuhs  in  fifteen  cases.  Pagano  mentions  surjirisinoiy  favourable 
effects  after  injecting  slerihzed  sea  water  in  quantities  from 
5  grammes  up  to  20-30  grammes  (sometimes  mixed  with  a  Httle 
iodine  till  it  lakes  a  straw  colour)  in  scrofulosis  of  the  lymph 
glands,  and  even  advanced  pulmonary  tuberculosis  (with  slight 
rise  of  temperature  and  often  with  enornious  appetite),  also 
involution  of  the  glands,  healing  of  fistula?,  tKrc,  and  effects 
similar  to  those  observed  after  a  stay  at  the  seaside  (see  also 
L.  Pernossi  and  Boutellier),  but  De  Lange  found  no  benefit  from 
it,  and  even  harm  with  high  fever,  &c. 

Whev  is  much  prescribed  in  health  resorts,  generally 
200  grammes  two  or  three  times  a  da_\',   fasting. 

Although  the  whev  treatment  is  not  so  much  used  as 
formerlv  and  has  no  specific  action,  the  dissenting  opinion  of 
many  authors  as  to  the  beneficial  effect  which  has  been  empirically 
demonstrated,  is  not  justified.  The  nutrient  value  is  small — 320 
calories — but  it  regulates  the  action  of  the  bowels,  helps  appetite 
and  digestion,  eases  diuresis,  and  loosens  the  secretions;  it  is 
also  much  liked  bv  children.  It  is  especially  suitable  for  the 
dilution  and  warming  of  mineral  waters.  Now  and  then  it  is 
refused  on  account  of  its  insipid  taste ;  in  rare  cases,  too,  it  is  not 
digested.  Limitation  of  diet  is  neither  demanded,  nor  is  it  allow- 
able for  scrofulous  patients  who  require  good  feeding,  but 
naturallv  the  food  must  be  such  as  is  easily  digested. 

In  many  places  the  scrofulous  are  ordered  a  glass  of  the 
freshlv  expressed  juice  of  medicinal  plants  before  noon.  The 
taraxacum  leontodon,  veronica  beccabunga,  nasturtium  aquati- 
cum,  menvanthes  trifol.,  glechoma  hederac,  &c.,  are  rightly 
valued  as  a  good  bitter  and  stomachic  for  toning  up  the  stomach, 
but  besides  this  are  of  no  great  importance. 

Often  systematic  air  and  sun  baths  are  combined  with  the 
climatic  treatment  on  account  of  the  tonic  effect  which  excites 
metabolism  and  to  get  the  full  action  of  the  sunlight.  The  real 
sunlight  treatment — heliotherapeutics — introduced  hv  Bernhardt 
in  Samaden  has  been  employed,  especially  bv  Rollier,  for  surgical 
scrofulosis  and  glandular  or  other  tuberculosis,  since  1903  in 
Leysin.  By  this  treatment  Rollier  does  not  open  closed  foci  over 
a  seat  of  infection,  but  exposes  the  patients  (in  the  case  of  open 
wounds  with  fixation  bandages)  to  the  sun's  rays,  and  keeps  them 
night  and  day  in  the  open  air.     The  wounds  become  healthy  and 


I  iii':i<Ai'i;i;i  ics  343 

dry,  gr.-iiiiilalc,  and  gi.'idii.'illy  lir-.-il.  I:s(  liciicli,  Monii,  and  v. 
Juselsb(M-g  have  coiivinif'd  llicm.s('lv(;.s  ol  siiilo'ng  successes  in 
lAjysin,  and  have  j)Lil)li.sli(;d  t.-icls  concerning  iIkui,  so  also  have 
IJardenlicucr,    I'^ran/.oni,    I  lirsclihcrg,  and  oiluis. 

The  lim(!  cxlcnds  lo  I  wo  yc'iis,  in  severe  cases  longer;  there 
is  no  improvcmeni  during  ilic  i.iiny  season.  DouhtU-ss  the 
intensity  of  the;  sun's  rjiys  in  llie  liigli  niounU'iins  ;is  in  Lcysin, 
eonlrihutes  largely  lo  die  success,  according  to  Morin  through 
the  ultra-violet  rays,  which  are  much  abstjrhed  in  the  ,-iimosphere 
of  places  lying  at  lower  levels  (see  Rollier).  Jerusalem  inffjrms 
us  that  he  has  had  good  resuhs  from  heliotherapeulics  in  the 
vicinity  of  Vienna  (see  Freund,  Sternberg,  and  others).  .Monti's 
observation  is  interesting,  namely,  that  in  contradistinction  'o 
patients  treated  with  tuberculin,  those  treated  with  sunlight  give 
a  characteristic  reaction  to  Moro's  test,  even  after  the  lesion  is 
healed  (Escherich ;  for  Heliotherapeutics,  "  see  also  Malgat, 
Borriglione  and  Alb.  Robin). 

F.— CHOICE  OF  A   HEALTH   RESORT. 

In  the  choice  of  a  climatic  health  resort,  or  mineral,  or  sea 
bathing  place,  a  number  of  points  of  view  must  be  taken  into 
account.  The  cost,  climatic  conditions,  in  many  cases  the  dis- 
tance, suitable  railway  communication,  the  possibilitv  of  com- 
bining the  stay  with  drinking  the  necessarv  waters,  &c.  It  is 
quite  impossible,  in  view  of  the  infinite  number  of  health  resorts 
and  baths  suitable  for  the  scrofulous,  that  a  single  observer 
has  a  sufficient  knowledge  of  them  all,  or  even  the  greater  part, 
therefore  in  the  following"  summary  we  shall  only  attempt  to 
mention  such  places  as  we  know  by  personal  experience,  or  those 
celebrated  as  being  especial Iv  suitable,  in  order  to  give  doctors 
a  certain  standpoint,  without  denying  efficacy  to  others  not 
mentioned. 

From  a  general  point  of  view  we  have  already  remarked  that 
the  sea  appears  to  be  less  suitable  for  weakly  and  excitable 
children,  and  for  such,  mineral  baths  are  more  desirable.  Of  sea 
bathing  stations,  those  of  the  North  Sea,  the  coast  of  Belgium 
as  far  as  Holland,  the  north  and  south-west  coasts  of  France,  and 
the  east  and  south-east  coasts  of  England  make  more  demand  on 
the  strength  of  the  patient  than  the  south  and  south-west  coasts 
of  England,  than  Arcachon  on  the  French  coast,  and  especially 
places  on  the  Adriatic  and  IMediterranean  Seas.  Here  again  the 
Riviera  di  Ponente  is  more  suitable  than  the  Riviera  di  Levante 


344  SCROFULOSIS 

for  ihe  weaklv,  bui   in  practice  ilie  indications  are  not  always  so 
sharply  defined  as  they  are  laid  down  in  theory. 

In  scrofulous  affections  of  the  ears,  as  already  mentioned, 
very  great  caution  must  be  exercised  with  baths.  Sea  baths  are 
almost  forbidden  in  affections  of  the  eyes,  mountain  and  sea 
climates  are  only  to  be  chosen  with  reserve  on  account  of  the 
slrone  reflection  of  lio-hi  ;  in  moist  acute  eczema  baths  must  be 
avoided,  and  even  a  slay  at  the  seaside  often  has  too  irritating 
an  effect. 

I.— Climatic  Health  Resorts. 

Health  and  Holiday  Resorts,  suitable  for  Spring  till  Autumn,  with   certain 
restrictions  according  to  level  above  the  sea. 

(i)  In  Inland  Plains  and  Heights  up  to  400  m. 

Numerous  health  and  holiday  resorts  in  Thuringia,  in  the 
Hartz  Mountains,  in  the  Bavarian  Alps,  in  the  Black  Forest,  in 
Tyrol,  in  Switzerland  :  — 

Thuringia  :  Berka  on  the  11m,  275-330  m. ;  Bad  Thai,  350  m. ; 
Tabarz  on  the  Inselsberg,.  420  m. 

Harz  :  Osterode,  230  m. ;  Ballenstedt,  264  m.  ;  Altenbrak, 
310  m.  ;  Bad  Sachsa,  325  m.;  Grund,  330  m. ;  Bad  Lauterberg, 
330  m. 

South  and  West  Germany:  Baden-Baden,  200  m.;  Cann- 
stadt,  Cleve  on  the  Lower  Rhine,  Bad  Triburg  in  the  Teutoburger 
Forest,  220  m.;  Braunfels  on  the  Lahn,  300  m. ;  Honnef  on  the 
Rhine,  Romberg  in  the  Black  Forest,  380  m. 

Taunus  :  Ems,  82  m. ;  Wiesbaden,  117  m. ;  Soden,  140  m. 

North  Germany  :   Eberswalde,  30  m. 

Austria  :  Gleichenberg  (Styria),  300  m.,  and  numerous 
others. 

(2)   In   Inland  Tablelands  and   Heights   from  400  to  900  m. 
(Simple  Mountain  Climates  and  Holiday  Resorts). 

Thuringia:   Friedrichsroda,  450  m. ;  iJmenau,  530  m. 

Bavaria  :   Bernek  in  the  Fichtelgebirge,  400  m. 

Black  Forest  :'Herrenalb,  near  Baden-Baden,  410  m. ;  Baden- 
weiler,  452  m.;  Triberg,  700  m.  ;  Freudenstadt,  740  m.  ;  St. 
Blasien,  772  m. 

Harz  Mountains:  Braunlage  in  the  Bodetal,  565-620  m,  ; 
St.  Andreasberg,  620  m. 

Riesengebirge  :  Wolfelsgrund,  600-700  m. 


TIII'KAFEUTICS  345 

(3)  Inland  1  lioKiiiis  oi-  400  loijoo  m.  (i  ndkr  yXi.i'iM-.  Inm.i  i-:nci-;, 

VOKAI.I'INI';   (  "l. I.MAI  I.). 

Germany:  Bad  J<ci(licnli.'ill,  470  in.;  I'x-n  lilesgadcn,  575  m.; 
Garmisch,  700  m. ;  ()l)(;rliol  in  'rimrin^na,  825  m.;  ( )bfrsif|f)rf 
im  Allgau,  843  m.;  iiad  Krciilli,  S^o  m. 

Austria:  Gmundcn  on   L;ikc  'I  i,-iiiii,  422  m.;  Isclil,  469  m. 

Hungary:    Marilla,  714  m. 

Switzerland:  GtM^sau  on  Lal<r  l>ii(  cnic,  440  in.;  Inicrlakon 
in  the  Bernese  ()l)erland,  568  m.;  Tliiin  on  l.ak'e  1  Inin,  57^  rn., 
I.angenbruck'  in  the  Jura,  740  ni.;  Biiij^ensloclc,  87fj  ni. 

(4)  IlKiii  Mountains,  900  m.  and  (jvkr,  also  sLriAHij-.  iok 

AF'ri<:R-TRI<:ATMKNT    AFTRR    MiNKRAL    BaTIIS. 

Germany:  Seebrugg  in  the  Black  Forest  of  Baden,  914  m.; 
H()henschwand  in  tlie  Black  Forest,  1,011  ni.  ;  Schreiberau  in  the 
Riesengebirge  up  to  1,200  m. 

Tyrol:  Igls,  near  Innsbruck,  (joo  m.  ;  Gossensass,  1,100  m.; 
Toblach  in  the  Puster  Valley,  1,224  m. ;  Brennerbad,  1,326  m.; 
Madonna  di  Campiglio  (South  Tyrol),   1,553  m. 

Hungary  :    Neu-Schmecks,    1,005  n^- 

Switzerland:   Felsenegg  (Canton  Zug),  950  m.;  Silz  Maria, 
Seewis,  1,000  m.;  Les  Avants,  near  Montreux,   1,000  m. ;  Engel- 
berg,    i,oig  m.;   Flims,    1,104-1,150  m.;    Beatenberg,    1,148   m. 
Churwalden,    1,270  m. ;   Adelboden,    1,356   m.  ;    Rigi,    1,600  m. 
Davos  Platz,  1,560  m. ;  Miirren,  1,650  m.  ;  Arosa,  1,720-1,860  m. 
Pontresina,  1,800  m. ;  Maloja,  1,811  m.  ;  and  St.  Moritz,  1,856  m. 

Transition  Resorts  suitable  for  Spring  and  Autumn. 

Tyrol  :  Arco,  90  ni. ;  Gries,  near  Bozen,  275  m.  ;  Meran,  319- 
520  m. 

Istria  :  Abbazia. 

Switzerland  :   Montreux,  380  m. 

Italy  :  Locarno,  204  m.,  and  Pallanza,  193  m.  on  Lake 
Maggiore ;  Lugano,  275  m. ;  Bellagio  on  Lake  Como. 

France  :   Pau,  Biarritz,  Dax. 

Late  Autumn  and  Winter  Resorts. 

Most  of  the  above-mentioned. 

Italy:  Gardone-Riviera,  the  Riviera  di  Levante ;  Rapallc 
St.  Margherita,  near  Genoa ;  Nervi  and  the  Riviera  di  Ponente ; 
Pegli,  Porto  Maurizio,  Bordighera,  Ospedaletti. 

France  :   Mentone,  Cannes,  Ajaccio  in  Corsica. 

Atlantic  Ocean  :  Madeira. 


346 


SCROFULOSIS 


II. — Watering  Places. 

D  =  for  drinking  ;    I  =  containing    iodine  ;   Ke  —  conlaining    iron  ;    As  =  containing 
arsenic  ;  S  ^  containing  sulphur  ;  CO.,  =^  containing  free  carbonic  acid. 

(I)  SIMPLE  MINERAL  WATEKIXC,   PLACi:s. 


((7)  Cool. 

Germany. 

Swinemiinde   and    Kolberg,    on    the  Baltic, 

2  —  5  ni.,  5  p^r  cent. 
Cammin,  10  ni.,  4.^  per  cent. 
Segeberg  in  llolstein,  48  m.,  26  per  cent. 
Essen,  nr.  Osnaliriick,  50  m.,  5 — 15  per  cent. 
Elmen,  nr.  Magdeburg,  55  m. 
Hohensalza,  96  m.,  25  per  cent. 
Inowrazlaw  (Posen),  96  m.,  31  per  cent.,  I. 
Wittekind,  nr.  Halle,  102  m.,  37  per  cent., 

D. 
Diirrenberg    on    the  Saale,    105    m.,    9   per 

cent. 
Kreuznach  (Rhine    Province),    105    m.,   D., 

i';^  per  cent.,  I. 
Gaudersheim,  107  m.,  I. 
Miinster  am  Stein  (Rhine  Province),  117  m., 

D.,  I  per  cent.,  I. 
Artern,  nr.  Erfurt,  130  m.,  3  per  cent. 
Frankenhausen     Kyffhauser,     130    m.,     D., 

2—27  per  cent. 
Suiza  on  the  Ilm,    148   m.,    D.,    12 — 27  per 

cent.,  I. 
Sooden  on  the  Werra,  152  m..  4  per  cent.,  I. 
Salzdetfurth  in  ihe  Ilaiz,  156  m.,  6  per  cent. 
Jagslfeld  in  Wiirtteniberg,  157  m. 
Soden-Salinunster,  157  m.,  3—4  per  cent. 
Kosen  in  Thiiringia,  163  m. 
Kostritz  in  Thiiringia,  165  m.,  22  per  cent. 
Thale  in  the  Ilarz,  180  m. 
Niederhronn,    Alsace,    192   m.,   D.,  0*4  per 

cent. 
Suderode  in  the  Harz,  200  m. 
Schmalkalden  in  Thiiringia,  232  m.,  D. 
Salzungen  in  Thiiringia,  262  ni. 
Goczalkowitz  (Pr.  .Silesia),  266  m.,    2'6    per 

Cent. 
Konigsdorf-Jastrzemb,  nr.   Loslau,   280  ni., 

D.,  I  per  cent. 
Harzburg,  300  m.,  D.,  16  per  cent. 
Wimpfen   on   the   Neckar,  300   m.,   28   per 

cent. 
Hall-Swabia,  301  m.,  28  per  cent. 
Reichenhall,      Bavarian     High     Alps,     D., 

470  m.,  23  per  cent.,  L 


Genu  a  II  y  —  continued. 

Berchtesgaden,  Bavarian  High  Alps,  575  m., 

26  per  cent. 
Diirrheim  (Black  I'^orest),  705  m. 

.liistria. 

Ischl,  469  m.,  I). 
Hall,  nr.  Innsbruck,  559  m. 
Aussee  (Styria),  650  ni. 
Iwonicz  (Hungary),  D.,  CO.,,  I. 

Switzerland. 

Rheinfelden,  270  m.,  31  per  cent. 
Bex-les-Bains,  430  m.,  D.,  31  per  cent.,  I. 
Aigle-les-Bains,  584  in. 

France. 

Lous-le-Saunier,  305  per  cent.,  I. 
Salies-de-Bearne  (Pyrenees),  40  m. 
Biarritz. 

Brides-Salins  (with  small  swimming  bath   for 
children),  490  m.,  I. 

England. 

Droitwich,  Worcestershire. 
Woodhall  Spa,  Lincolnshire. 

Italy. 

Battaglia  (Abano). 

Salsomaggiore  in  Parma,  I5'3  per  cent.,  1. 

Castro-Caro,  nr.  Florence,  I. 

{/})  Warm. 

Geniiaity. 

Baden-Baden,    200   m.,    D.,  o'2    per  cent., 

CO.,. 
Wie.sbaden,  117  m.,  D.,  08  per  cent.,  CO'3. 

France. 

Bourbon-l'Archambault,  270  m.,  D. 
Bourbonne-les- Bains,  275  m. ,  D. 


■\\\\:u,wi-.in\(:s 


347 


(2)  CARBONIC  ACID  MINKRAI,  WATKKINC   I'LACEIS. 


(j'eniKuiV' 


Ilamm  in  Westphalia,  6t,  m.,  8  per  cent. 
Oeynhausen,  71m.,  3—8  per  cent. 
Salziiden,  I^ippe,  75  ni.,  4  percent. 
Sotlen  in  the  Taiiniis,  140  m.,   D.,  o'j— f6 

per  cent. 
Nauheim,  Ilesse,  183  m.,  I).,  2  -4  per  cent, 
riomhur^,  the  Ileiglits,  192  ni.,  I).,  I'"e. 
Kissingcn,  Bavaiia,  201   m.,   I).,    i      10  ))er 

cent. 
Cannstadt,  nr.  Stuttgart,  220  m.,  I). 
Neuhaus   (Lower   Franconia),    220    m.,    I)., 

0"9—  17  per  cent. 


Eisenach,     Thiiringia,      220-396     in., 

I  "3  per  cent. 
Berg,  nr.  Cannslarlt,  230  m.,  D.,  P'e. 
Salzschliif,  nr.  Kulda,  250  m.,   D.,   Ke., 

I  — I "5  per  cent . 
CottesgaJjc,  Westphalia. 
Kiinigsljorn,  Westf>iialia,  D. 
Salzhaiisen,  Hesse,  I).,  i'"e. 


Orb,  Spt-.ssart.  U.,  o-8      18  pf 
Rothenfelde,  Hanover,  112  m 


r  cent. 


(3)  IODINE  DRINKING  SI'KING.S. 


Germany. 

Sodenthal,  Spessart,  142  m. 
Tolz-Krankenheil  (Upper  Bavaria),  670  m. 
Heilbrunn  (Upper  Bavaria,  Adelheid  Spring), 

800  m. 
Sulzbrunn,  Bavarian  Allgau,  875  m. 


Austria. 

Darkau,  Silesia. 

Lipik  (Siavonia),  154  m. 

Hall,  Upper  Austria,  376  m.,  13  per  cent. 

Rabka  (Galicia),  540  m. 

Szuitzerlaiid. 
Rothenbrunnen,  614  m.,  Fe. 


(4)  ALKALINE  SPRINGS. 


Germany. 

Ems  (Rhenish  Prussia),  82  m. 
Neuenahr,  Rheinland,  93  m. 

Austria. 

Gleichenberg  (Styria),  300  m.,  D. 
Luhacovice  (Moravia),  1. 


Sivitzerlaiid. 

Passugg,  nr.  Chur,  829  m.,  D..  I.,  Fe. 
Tarasp,  Engadine,  1,200  —  1 ,240  m..  0"2  —  i  '5 
per  cent.,  D.,  Fe.,  CO.j. 


(5)   IRON  AND  ARSENIC  SPAS. 


Germany. 

Pyrmont-Waldeck,    120  m. ,    D.,    Fe.,    i — 3 

per  cent,  salts. 
Diirkheim    (Rhenish    Palatinate),     130    m.. 

D.,  As.,  2  per  cent,  salts. 
Elster,  Saxony,  500  m.,  D. ,  Fe.,  CO.j. 
Flinsberg,    Silesia,    521-970   m.,    D.,     Fe., 

CO.,. 
Reinerz,  Silesia,  568  m.,  D.,  Fe.,  CO.,.,  I. 

Austria, 

Levico-Vetriolo  (S.  Tyrol),  500  m.,  D.,  As.,  : 
Fe.  ! 

Roncegno  (S.  Tyrol),  525  m.,  D.,  As.,  Fe. 


Switzerland. 

Rothenbrunnen,  614  m.,  D.,  Fe.,  I. 

Val  Sinestra,  Engadine,  1,485  ni.,  D.,  Fe. 

As. 
St.  Moritz,  1,800  m.,  D.,  F'e. 

France. 

Saint  Honore,  300  m.,  As. 

Royat,  450  m.,  D.,  Fe.,  As. 

Brides  Salins,  490  m.,  D.,  As. 

Saint  Nectaire,  760  m.,  Fe.,  As. 

La  Bourboule  Puy  de  Dome,  800  m..  D.,  As 


Sweden. 


Ronnebv.  D.,  Fe. 


548 


SCROFl'LOSIS 


(6)  SULPHUR  SPAS. 


Germany. 

Oldesloe,  Holstein. 
Langensalza,  Thuringia. 
Nenndorf,  nr.  Hanover,  71  m.,  D. 
Weilbach  in  the  Taunus,  135  m.,  D. 
Meinherg,  Lippe,  210  m.,  D. 
Landeck,  Silesia,  450  m. 

Fraiue. 

Amelie-les- Bains,  225  m. 
Challes  (Savoy),  270  m. 
Uriage,  414  m..  As. 

Bagnieres   de   Luchon  (Department    Haute 
Cjaronne),  630  m. 


France  -continued. 

Ax  (Upper  Pyrenees),  714  m.,  D. 
Cauterets  (Upper  Pyrenees),  930  m. 
Bai^ges,  hautes  (Upper  Pyrenees),  1,240 
Pierrcfonds. 
Enghien. 

Swilzeiland. 

Schinzach  (Canton  Argau),  343  m. 
Stachelberg  (Canton  Glarus),  664  m. 
Gurnigl  (Canton  Berne)  1,155  "^-j  ^^• 

England. 
Harrogate,  with  various  springs. 


(7)  SEA-BATHING  PLACES  (ARRANGED  FROM  EAST  TO  WEST). 


Baltic. 
Cranz. 
Zoppot. 
Stolpmiinde. 
Kolberg  (Pomerania). 
Berg-Dievenow  (Pomerania) 
Misdroy. 
Swinemiinde. 
Ahlbeck  in  Usedom. 
Heringsdorf. 
Zinnowitz. 
Gohren  in  Rtigen. 
Sellin. 
Binz. 
Sassnitz. 
Breege. 

Miiritz  (Mecklenburg). 
Warnemlinde. 
Doberan. 
Boltenhagen. 
Heiligendamm. 
Travemiinde. 
Gliicksburg. 
Marienlyst  (Denmark). 


North  Sea. 


Fano  (Denmark). 
Wyk  in  Fohr. 
Amrum. 
Biisum. 
Heligoland. 


North  Sea — conlintied. 


Spickeroog. 

Norderney. 

Juist. 

Borkum. 

Zandvoort  (Holland). 

Scheveningen  (Holland). 

Blankenberghe  (Belgium). 

Ostend  (Belgium). 


Atlantic  Ocean. 
En  0^1  and. 


Brighton. 
Hastings. 
Isle  of  Wight. 

Madeira. 

Dieppe. 
Trouville. 
Arcachon. 
Biarritz. 


Portn^al. 
France. 


Mediterranean. 


Abbazia. 

Grado. 

Venice-Lido. 

Pegli. 

Sestri  Levante. 

Via  Reggio. 


'mi;RAiM:i;Tjcs  349 

G.— HOLIDAY  SETTLEMENTS  AND   CHILDREN'S 
CONVALESCENT  HOMES. 

Coiiiparalivcl)  l(;\v  laiDJIics  can  alTord  lo  pay  lor  (Ik*  stay 
of  a  scrofuUnis  child  in  a  licalLJi  resorl,  still  less  Uj  accfjmpany 
llie  child.  Therefore  in  rcxenl  years  public  charily  has  untJer- 
faken  tlie  task  of  sending  invalid  children  of  [)oor  parents  for  a 
time  to  suitable  |)laces  and  c:aring  f(jr  them  there.  '1  his  is  done 
in  holickiy  settlements,  and  in  mineral  and  sea  health  resorts. 

In  the  holiday  settlements  delicate  poor  children,  chiefly  aged 
from  6  to  8  or  14  years,  are  sent  in  batches  of  twelve  to  twenty 
or  forty  to  good  country  air,  either  to  homes  or  to  families  or 
hired  places  for  tliree  or  fcjur  weeks;  in  day  settlements  and  milk 
stations,  the  children  assemble  at  a  certain  place  in  the  town  to 
drink  milk,  and  to  be  taken,  under  proper  supervision,  into  the 
forest,  fields,  or  playgrounds.  Mineral  and  sea  hospitals  take 
children  who  are  really  ill,  and  chiefly  the  scrofulous. 

In  the  year  1876  a  batch  of  poor  children  was  first  taken  into 
the  country  to  a  holidav  settlement  by  Pastor  Bion  in  Zurich, 
and  about  the  same  time  in  Hamburg.  Since  then,  especially  by 
the  untiring  efforts  of  Dr.  Varrentrapps  in  Frankfort-on-Main, 
this  humane  movement  has  embraced  a  wide  field  in  Germany, 
thanks  to  good  organization.  According  to  the  reports  of  the 
central  station  in  Germany,  in  1880  over  1,000,  in  1890  over 
20,000,  in  1898,  28,000,  and  the  total  since  the  beginning  of  the 
movement  of  over  266,000  poor  children  have  shared  the  benefit 
of  a  longer  summer  stav.  In  nearly  all  the  countries  of  Europe, 
partly  also  in  America  and  Japan,  this  splendid  idea  has  been 
appreciated  and  made  a  reality. 

We  cannot  even  approximately  reckon  the  value  which 
holiday  settlements  have  in  the  avoidance  of  scrofulosis,  and  in 
the  cure  of  slight  cases  owing  to  the  want  of  proper  statistics 
relating  to  scrofulosis,  but  doubtless  the  use  is  enormous,  as  we 
may  conclude  from  the  general  gain  in  strength  of  the  children 
who  have  enjoyed  the  benefit.  Very  favourable  results  are 
rightlv  attributed  to  day  settlements  and  milk  stations.  The 
weight  of  the  body^  gives  a  relatively  reliable  criterion  for  the 
success,  in  spite  of  many  just  objections. 

Comparative  weighing  of  the  settlement  children  and  those 
who  remained  at  home  showed,  with  the  former  (in  Leipzig),  an 
increase  of  double  (1,700  and  1,500  respectively,  against  700  and 

^  Monti  only  allows  a  definite  cure  of  scrofulosis  if  besides  the  disap- 
pearance of  the  local  processes  there  is  an  addition  of  more  than  2  kilo- 
grammes in  weight. 


Jo^ 


SCROI-L'LOSIS 


7S0  grammes);  in  Frankforl-on-.\l;iin  ihere  was  even  r2  to  r8 
kilogramme  increase,  against  01  U)  c)'4  of  children  not  sent  to  a 
settlement.  According  to  Biising's  esiimaie,  in  2,622  cases  the 
children,  lo  judge  by  comparisons  in  weight,  were  furthered  in 
their  development  by  J  to  5  of  a  year  by  a  stay  lasting  about 
three  weeks  in  the  summer  in  a  settlement. 

In  some  lowns,  Dresden,  Mayence,  Frankfort-on-Main,  an 
after  or  winter  treatment  is  practised  by  giving  the  children  milk, 
&c.  By  this  means  especially  the  improvement  in  health  attained 
in  the  settlements  proves  to  be  a  lasting  one,  as  was  shown  by  a 
later  weighing  (in  Mayence,  for  instance),  and  a  smaller  number 
of  absences  from  school  (Ratisbon).  The  principal  result  was 
frequently  attained,  according  to  Goepel  in  Frankfort-on-Oder, 
only  in  the  folU)wing  months,  so  that  the  holiday  change  acts 
"  like  an  accumulator  of  energy  of  growth  to  form  strength." 

Before  the  introduction  of  holiday  settlements  arrangements 
had  been  made  in  mineral  watering-places  for  the  reception  of 
poor,  weakly  children,  especially  the  scrofulous.  The  merit  of 
instituting  the  first  mineral-bath  hospital  in  Germany  belongs  to 
Dr.  A.  H.  Werner,  of  Ludwigsburg.  He  succeeded  after  much 
trouble  in  1861  in  building  at  the  Yagstfeld  Spa  his  own 
Children's  Mome,  which  from  1862  to  1898  received  nearly  10,000 
children.  Now  there  are  over  thirty  German  homes,  which  in 
1898  received  11,000.  Later  the  Central  I'nion  for  Children's 
Homes  and  the  Fatherland's  Women's  Cnion  liave  made  the 
furthering  and  foundation  of  children's  home  their  special  task. 
At  present  there  are  the  following 

Children's  Homes  in  Germany. 

For  Children  threatened.  witJt  Tuberculosis,  tlie  Scrofulous,  and 
Convalescents. 

(1)  In  Mineral-water 

Spas  44  Institutions — 4,Qi7  beds,    10  open  during  Winter 

(2)  In  Seaside  Hospitals  41  ,,  3,4'5      ,,         9      ?>  ■>•,  ,, 

(3)  In    other    Places  16  ,,  807      ,,         5      ,,  ,,  ,, 

For  Tuberculous  Children. 

(i)  In  Mineral-water 

Spas  3  Institutions —     155  beds,     8  open  during  Winter 

(2)   In  other  Places  16  ,,  774      ,, 

Such  institutions  have  existed  in  Austria,  in  ]5ad  Hall  since 
1856,  and  in  Sulzbach,  near  Ischl,  Darkau,  Lipik,  and  Ilallein. 

Practitioners  would  perhaps  like  to  be  informed  of  the 
children's  homes  which  exist,  in  case  it  might  become  necessary 
to  choose  one. 


Tin:KAi'i:iJ7ic.s 


.5.-)  I 


I.     CirrLDKKN'S   IIOSI'IT/M.S   IN   fiKRMAN  SPAS. 

(A)    J'V}K    'IIIOSIC     rilKKAl  KNKI)    WJIll    T  li  UKKCIJ  i.OSIS,    'lUK    SCKOKIj  r.OIJ  S    AMv 
CV)NVAI.ESCKNTS. 

As  a  rule  thuy  arc  oi)an  from    May  to  September,  or  Octoljer.      Institutions  open   the 
whole  year  arc  marked  thus  * 


Name  ami  place  of  ChiM, .,,  :,  l,.,;,i<ii..l 

Cnart;';  lu  iii.im  s 

■j:  j;  ~ 

Cli.— Cliildreii's  lioipital 

¥r.  —  Home  free 

9  c 

Ch.H. — Cliiltlrcn's  home 

Age  for 

Age  for 

girls 

Boys 

-6  E?( 

In  Si'As. 

C    3 
rt  JO  ■ 

Convalescent    home    and    (jirls' 

32 

1 05  per  week 

W    £ 

Refu{;e,  Kberswalde' 

5-4 

Fr. 

i  1 

Prince     and     Princess     William 

40 

7 — 875  per  week 

Ch.  Ilohensalza 

6  —  14 

Fr. 

Bethesda  Ch.,  Goczaikowitz      ... 

100 

1 7*5  per  week 

3-'4 

Konigsdorff-Jastrzein,  Jewish  Ch. 

45 

9'8  per  week 

*Empress    Augusta,   Ch.    I.    Bad 

100 

6075 

>> 

Elmen-Salze 

2 — 16  1  2—12 

per  4  —  6  weeks 

*Empress    Augusta   Ch.   II.    Bad 

100 

60—75 

X 
rt 

Elmen-Salze 

2  -16  1  2 — 12 

per  4 — 6  weeks 

C/3 

Ch.  H.  III.  Bad  Elmen 

30 

Fr. 

<u 

7—14 

o 

B 

O 

Cecilia  Refuge,  Artern  ... 

32 

40— 60  per  month 

4—14  1  4—13 

£ 

Empress    Augusta  Victoria,  Ch. 

70 

60-75 

Bad  Kosen 

3—14 

per  5—6  weeks 

\ 

Siildorf  Ch.,  nr.  Osterweddingen 

25 

875  per  week 

2—16  1  3—14 

^1 

Oldesloe,  Ch 

80 

35—50 

S     "5    • 

5-«5 

per  4  weeks 

Oldeslue       Children's       Nursing 
Home 

30 

65  per  4  weeks 

; 

*Liineberg  Children's  Hospital  ... 

65 

I0"50  per  week 

I— IS  1  I— 14 

g 

Salzdetfurth  Ch.              

180 

iO'5 — 245  per  week 

B      ' 

3-12 

w 

EHzabeth  Hospital,  Rothenfelde 

105 
4-15  i  4—13 

37 "5 — 100  permon'.h 

.2    / 

Kdnigsborn  Ch.   ... 

103 

10-5 — 14  per  week 

"cS 

7—14 

Fr. 

J3 

Ch.  Bad  Sassendorf        

172 

35 — 60  per  month 

4) 

Emperor    William  and  Empress 

40 

For  children  of  the  Harpen 

^ 

Augusta- Victoria    Home,   Bad 

S-14 

coal  miners.     A.  G.  Dort- 

Sassendorf 

mund. 

3 
C3 

Soden  in  the  TaunusCh.  H. 

13 

14  per  week 

rt 
^1       - 

6—14  1  6—10 

Ch.  Bad  Orb       

350 

45—60 

<U 

3—14 

Per  4  weeks 

Fr. 

X     ^ 

Ch.  Sooden  in  the  Werra 

107 

45-75 

<"    , 

3—14  1  3—12 

Per  4  weeks 

Rhine 
Provinc 

Victoria    Institulion     Ch.     Bad 

290 

1 2 '25  — 14  per  week 

Kreusnach 

4-15  1  4—13 

Children's  Spa,  RafTelberg 

150 

105  per  week 

4—14 

Fr. 

1 

Bad  Reichenhall  Ch 

38 

iO"5  per  week 

5—16  1  — 

Fr. 

>    -i 

Bad  Kissengen  Ch. 

50 

9  "So  per  week 

rt 

5—13 

The    Palatine    Ch.     Bad    Dlirk- 

170 

II  CI.  70  per  month 

heim  in  the  Hardt 

3—16  i  3—14 

I  CI.  100  per  month    Fr. 

3D' 


SCROFULOSIS 


(A)  For  those  threatened  with  Tubercuiosis,  the  Scrofulous,  and 
Convalescents— <-^m/7;///^</. 


Number  of  beds 

sis 

Name  and  place  of  Children's  hospital 

Charge  in  marks 
Fr.  —  some  free 

■>[vi^l                    Ch.— children's  hospital 

2=                         Ch.H.— children's  home 

Age  for 

Age  for 

£8 

girls 

hoys. 

<-        1 

Bethlehem  Ch.  BerggiesshUbel... 

70 

Al)out  7" I  per  week 

^        1 

^       1 

3-«5 

Fr. 

i  = ' 

Bethlehem  Ch.  Bad  Elster 

34 

12  per  week 

i°^i 

I— 14 

Fr. 

'O       1 

Bethlehem  Cli.  Lausigk' 

130 

8'75 — iO'5  per  week 

^       1 

Leipzig  Ch.  H.  Dl'irrenberg 

3  -  '4 

40 

4*5  per  week,  only  for  chil- 

6— [4 

dren  from  Leipzig 

/ 

Bethesda,  Ludwigsburg  Jagstfeld 

120 

9  —  1 9 '6  per  week 

bo 

2-15 

J3 

*Ch.    of    the    Johanniter    Order, 

90 

g- 1  per  week 

s   , 

Hall,  Swabia 

4—15 

V 

"A.    H.    Werner's  Ch.    Ludwigs- 

200 

3"5  —  7  P^""  week 

:3 

burg 

4—18 

Also  cripples,  surgical  and 

^ 

orthopixidic 

Herrenhilfe  Ch.  IL  Wildbad    ... 

52 
2—17  !  2— ic; 

9—19-6  per  week 

=       r 

Children's  Spa,    "  Silvah "   Rap- 

75 

50 — 70  per  4  weeks 

■S 

penau 

"1 

'Children's  Spa,  Dlirrheim 

120 
3-15 

126 — 17'5  per  week 

<L) 

"Elizabeth  Home"  Ch.  Nauheim 

200 

40 — 70  for  whole  treatment 

3-15  1  3—14 

Fr. 

U^       , 

—   u 

"  Bethesda"  Ch.  Siilze 

4C0 

45  per  month 

V    c  - 

3—16  1  3—14 

Kr. 

2  5 

Ch.  Bad  Ilarzburg          

16s 

8'75 — lO'S  per  week 

o  rn 
4)  i— 1 

4—14 

IS^ 

/ 

Children's  Spa,  Bad  Suiza 

82 

io'5  per  week. 

c 

3—14  1  3—12 

ex  QJ 

Charloitenhall  Ch.  Salzungen  ... 

94 

•=^i 

Ch.  Frankenhausen 

120 

45 — 65  per  4  weeks 

3-14  ,  3—13 

"Helen"  Ch.  H.,  Pyrmont      ... 

100 

7 — 14  per  week 

Ch.  Salzuflen       

308 
4—14 

8'75 — 12-25  P^"^  week 

1  Eberswalde  and  Lausigk  have  oiilj'  iron  springs. 

(B)  For  Tuberculous  Children. 


In  Mineral  Watering  Places 

Prince    and     Princess     William 

60 

9'8  per  week 

Children's    Hospital,    Hohen- 

6 — 14 

Fr. 

salza 

Ch.  H.  Lippspringe 

5— 

20 
16  1  5—14 

14 — 1 7 '5  per  week 

Caecilien  Institute,  Ch.  H.  Lipp- 

55 

15-75— 19-25  per  week 

springe 

4— 

16  1  4—14 

TIIKKAPKUTICS 


353 


ir.— OTIIKR  CHILDRKN'S   IIOSiTIALS  (nol  in  Spas). 

(A)   I'OK     I'HOSK    rilKK.AIICNKlJ    VVIHI    TuilKRCULOSIS,     IIIIC   SCKOrrj  I.OtJS,    ANI»    I  KOSK 
NKKDINC     RkST    AND    ClIAN'JK. 


°f 

Number  of  beds 

<j  V  a 

Naiiii;  ;iik1  phicc  of  Cliiltlrcii's  hospital 
Ch. — Children's  liospit.'il 

CliarKe  in  marks 

I'"r. —  »ome  free 

0  B 

£8 

Ch.H.— Children's  home 

Arc  for        Age  for 

girls             IJoys 

/ 

Berlin  Ch.  Borgsdorf,  nr.  Birken- 

34 

14  per  week 

J  tjj 

werder 

4—14  1  4—10 

Fr. 

■T3  ir' 

(3    3  - 

Elizahetli  Ch.  H.  Burgsdorf,  nr. 

22 

Ir. 

rt  X> 

Birkeiiwcrder 

S-4  1  .?-4 

m 

*Ch.  Gross-Lichtenfelde  West 

60 

4—14 

13-25  per  week 

•^       ( 

Ch.    Lenzheim,  Schreiberau     ... 

60 

84— 9" I  per  week 

5-15  1  5-9 

Villa  Klause,  Gorhersdorf 

12 

— 

*Ch.  Halle  on  the  Saal 

70 

I0"5 — 21  per  week 

^J?  ^ 

2  —  16    2—14 

Fr. 

Bevensen,  Hanover 

52 

io'5 — 14  per  week 

5-15 

A   CS    C 

Ch.  nr.  Schalksmiihle     ... 

100 

Fr. 

7-14 

^-al 

*Ch.  Wildeborn 

24 

8  "4  per  week 

^i 

Nastatten 





ffill 

^  /" 

Bethlehem     Institute   Augustus- 

80 

About  7  weeks 

O 

Bad,  nr.  Radeberg 

3— '4 

Fr. 

Bethlehem  Institute,  nr.  Zittau 

32 

7  per  week 

^       j 

4—14 

Fr. 

o    -, 

Bethlehem     Institute,     Hiitten- 

165 

7  per  week 

S 
o 

grunde  (Hohenstein-Ernstthal) 

3—14 

Fr. 

CuO 

c 

Bethlehem  Institute,    Niederneu- 

5° 

7  per  week 

kirchen,  nr.  Bautzen 

3—14 

Fr. 

w    ^ 

Bethlehem  Institute,  Zwonitzthal 

32 

7  per  week 

/ 

3—15  1  3—14 

Fr. 

L. 

Heilbronn  (Ebenezer) 

14 

5 — 6  per  week 

k-H  . 

Fr. 

4->      )H 

)-<      (U 

mostly  surgical 

g-l 

tuberculosis 

(B)  For  Tuberculous  Children. 


East 
Prussia 

Ch.  Waldfrieden,  nr.  Gerlanken 

12 

io'5  per  week 

5— II 

bfl    / 

*Ch.  Belzig            

36 

1 7 '5  per  week 

3 

6-15 

Fr. 

*Ch.  Victoria  Louisa  Hohenlychen 

150 

1 7  5  per  week 

<u      1 

4 — 16 

Fr. 

c 

Caecelia  Home,  Hohenlychen  ... 

150 

1 7 '5  per  week 

i^ 

m 

4—16 

Kd.  Buch  nr.  Berlin 

100 

Projected 

rt 

Division        Gorbersdorf,        Dr. 

10 



(U 

Weicker's  People's  Sanatorium, 

C/} 

Home  for  Invalids 

23 


354 


SCROFULOSIS 


(B)  For  Tuberculous  Children— coniinued. 


Number  of  beds 


Name  and  place  of  children's  hospital 

Ch. — Children's  hospital 
Ch.H. — Children's  home 


Age  for 
girls 


Charge  in  marks 
Fr. —  some  free 


on 


W)  re    i 


^     J 


ffi 


Ch.  Frauenhilfe,  Aschersleben. 


Division     in     Waldhof     Elgers- 
hausen 

Ch.  Aprath  

Louisa     Gueury     Institute,      nr. 

Gladbach 
Provincial    Nursing    Home    and 

School,   Rheindehlen 


'Division  Carolagriin 


*Division  in  Boblingen 


Ch.  Duchess  Maria  nr.  Oranien- 
baum 


Reichelsheim  in  Odenwald 
Pfastatt,  nr.  Miilhausen... 


Fr. 

Extension  projected 


I7'5 — 21  per  week 
17*5  per  week 


14 — 17'5  per  week 
l<r. 


45 — 70  per  week 
Also  for  bone  tuberculosis 

1575 — 1 7 '5  per  week 
Fr. 


23  per  week 


Seaside  hospitals  have  been  established  for  some  time,  the 
example  having  been  started  by  England  in  1796;^  through  the 
energy  of  Lettsom  and  Latham  the  first  institution  for  poor 
children  was  founded  in  Margate,  which  was  soon  followed  by 
others.  At  present  England  possesses  (over)  fifty-three  seaside 
hospitals.  It  was  forty-five  years  later  (in  1841)  that  a  seaside 
hospital  for  scrofulous  children  was  instituted  outside  England, 
in  Italy,  at  Viareggio,  through  the  initiative  of  Barellais,  the 
founder  of  Italian  seaside  homes,  whom  his  country  may  thank 
for  about  twenty  of  such  beneficent  institutions.  Now  there  are 
about  thirty-six  seaside  hospitals. 

The  development  of  seaside  hospitals  in  France  is  due 
especially  to  Perrochaud,  Bergeron,  and  Armaingaud.  There 
are  at  present  about  forty  in  existence. 


^  In    17Q1. — Translator. 


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358  SCROFULOSIS 

France. — Arcachon  (Dep.  Gironde)  with  2  Homes,  260  beds;  Banyuls-sur-Mer 
(200  beds) ;  Berc-sur-ISIer,  on  the  Englisn  Channel,  with  5  Homes,  over  2,000  beds  ;  Cape 
Breton  (120  beds),  on  the  Bay  of  Biscay;  La  Croisic  (250  beds);  Giens,  nr.  Hyeres  (150 
beds)  ;  Hendaye  (592  beds) ;  Pen  Bron  (300  beds),  nr.  Croisic  ;  Saint  Pol-sur-Mer  (420 
beds),  Dep.  du  Ni)rd  ;  Saint  Trojan  (200  beds),  on  the  island  Oleron;  San  Salvador  (200 
beds),  on  the  Mediterranean  Sea;  Zuydcoote  (1,000  beds),  on  the  Belgian  frontier.  All  the 
above  open  the  whole  year.  Further  Cannes  (formerly  Dollfiis  Asylum,  50  beds)  :  Cette 
(Alpes  maritimes),  with  3  Homes  and  nearly  1,000  beds  ;  and  a  number  of  institutions  with 
under  100  beds. 

In  Berc-sur-Mer  (Pas  de  Calais),  ^^alo-les-Bains,  and  Royan  Ithere  are  [sever;il  homes 
for  children  of  well-to-do  parents ;  per  day  3 — 8  francs. 

Italy. — Palermo  (i  So  beds) ;  Porto  d'Anzio  (200  beds);  on  the  Mediterranean  .Sea, 
Via  Reggio ;  these  are  open  the  whole  year.  Further,  Alghero  (80  beds),  in  Sardinia; 
Eagnoli,  in  the  Province  of  Naples  ;  Bocca  d'Arno  (130  beds),  nr.  Pisa  ;  Celle  Ligure,  nr. 
Genoa,  with  3  Homes  and  1,000  beds;  Cesenatico  (120  beds);  Falconara  (no  beds); 
Fano  (350  beds)  ;  Fontespina  (no  beds);  Giula  Nova  (150  beds),  on  the  Adriatic  Sea  ; 
Loano  (250  beds),  nr.  Genoa ;  Porto  Corsini  (80  beds);  Porto  San  Stefano  (180  beds); 
Riccione,  vrith  4  Homes  and  1,250  beds;  Rimini,  with  4  Homes  and  more  than  600 
beds;  Sestri  Levante  (160  beds),  nr.  Nervi  ;  Venice  (450  beds);  Via  Reggio,  with 
2  Homes  and  about  470  beds  ;  Voltri  (300  beds),  nr.  Genoa  ;  further,  numerous  relatively 
smaller  hospitals. 

England. — On  the  south  coast,  Bournemouth  (72  beds);  Brighton,  Millfield  (100 
beds);  St.  Leonards  (103  beds).  Rhyl  (250  beds),  in  North  Wales.  In  the  County  of 
Kent:  Heme  Bay  (134  beds);  Broadstairs,  with  5  Hospitals  and  600  beds;  Margate, 
with  4  Hospitals  and  500  beds,  amongst  the  best  arranged.  Eastbourne  (340  beds),  on 
the  coast  of  Sussex  ;  Felixstowe  (128  beds)  ;  Folkestone  (147  beds)  ;  New  Brighton  (100 
beds);  St.  Annes-on-Sea  (154  beds);  St.  Margaret's  Bay  (250  beds);  Scarborough 
(103  beds);    Silloth    (105   beds);   Southport    (no   beds);  Withernsea  (106  beds),  &c.'' 

Russia. — Alupka  and  Yalta  in  the  Crimea  ;  Windau  in  Kurland  ;  Arensburg,  on  the 
coast  of  Osel  Island  ;  Assern  ;  Neubad  and  Bilderlingshof,  on  the  Gulf  of  Riga  ;  Budak  ; 
Chadshibei  and  Odessa,  on  the  Black  Sea  ;  Haspol,  Sestrorczk,  Hogsand  and  Worms  on  the 
Gulf  of  Finland  ;  Oranienbaum  in  the  Russian  Government  of  St.  Petersburg. 

Holland. — Scheveningen,  Domburg  and  Oost-Capelle,  on  the  Island  of  Walcheren  : 
Katwijk  aan  Zee  and  Nordwijk  aan  Zee  in  the  Province  of  South  Holland  ;  Loosduinen, 
nr.  Scheveningen  ;  Zandvoort  and  Egmond  aan  Zee  in  the  Province  of  North  Holland  ; 
Wijk  aan  Zee. 

Belgium.— Blankenberghe,  Ostend,  Middelkerke,  Venduyne-sur-Mer  and  Villa 
d'Uytkerke,  nr.  Blankenberghe,  Heyst-sur-Mer,  Villa  Westende. 

Denmark. — Juelsminde  and  Odder,  on  the  east  coast  of  Jutland  ;  nr.  this  Buddesminde  ; 
Refsnaes  and  nr.  this  Bakkely,  Kolding,  Frederiksberg,  Hellebaek ;  not  far  from  this 
Munkerup,  Gilbjaerg,  Snogebaek  on  the  Island  of  Bornholm. 

Sweden. — Skelderviken  on  the  Cattegatt,  Styrso,  nr.  Gothenburg,  Apelviken  and 
Halsan  in  Antnas,  nr.  Bigdea. 

Norway. — Blekoen,  nr.  Christiania,  Fredriksvaern  on  the  Skagerak,  Hageviken,  nr. 
Bergen,  Vikan,  east  of  Drontheim. 

Spain.- — Chipiona,  not  far  from  Cadiz,  San  Vicente  de  la  Barquera,  La  Coruna, 
Santander. 

Portugal. — Carcavellos,  not  far  from  the  mouth  of  the  Tagus  ;  Gel  fa,  nr.  Caminka  ; 
Outao  at  the  mouth  of  the  Sadun  ;  Parede  in  the  Province  of  Estremadura,  Figueira  da 
Foz,  Oeiras,  Trafaria. 

Greece. — Oropos,  on  the  Gulf  of  Eubcea. 

Rumania. — Tekir-Ghiol,  on  the  Black  Sea. 

Turkey. — The  Island  Aniigoni,  on  the  Sea  of  Marmora,  the  summer  station  of 
a  hospital. 

North  America. — Cape  May,  in  Pennsylvania;  Beverly  Farms,  in  Massachusetts; 
Atlantic  City  (founded  by  Philadelphia)  ;  Vinlhrop,  nr.  Boston;  Barth,  nr.  New  York; 
Hospitals  of  Baltimore,  swimming  hospitals  in  Rockaway  (New  York)  and  on  Lake 
Michigan  (Chicago). 

Argentina. — Mar  del  P.'ata. 


THERAPEUTICS  359 

In  Germimy,  in  1876,  on  lli<;  isl.'uid  ot  Soiuh-A-ncy,  a 
deaconess'  instil  iii  ion  w.-is  lonndcd,  vvliicli  look  in  scrofulous 
children  amongst  oliiers.  In  iIk;  year  j88i  I'v.  iienelce  succeeded 
in  founding  a  "Society  for  C'liildren's  (>)nvalescenl  Homes  on 
the  sea  coasts  oi  Germany,"  i)y  iIh-  insiriimenlalily  of  which,  in 
1882,  the  Empress  T^rederick  llospital  was  opcnf;d  in  Ntjrderney, 
and  in  the  following  yc^ar  a  cliildren's  ccjnvalescent  home  in 
Wyk  in  Fohr,  &c.  Later  the  "  Society  for  (Children's  Con- 
valescent Homes  on  the  Sea  Coasts  of  Germany,"  by  the  energetic 
endeavours  of  Ewald  and  Baginsky,  has  devoted  itself  to  the 
foundation  of  seaside  hospitals  with  such  success  that  now  forty 
seaside  homes  with  3,415  beds  are  open  to  patients.  From  1885 
to  1898,  27,000  children  were  cared  for. 

School  Sanatoria. 

If  we  wish  to  attain  anything  thorough  we  must  break  away 
from  the  idea  of  a  four  to  six  weeks'  treatment.  For  real  success, 
as  a  rule,  a  long  course  of  treatment  is  necessary  from  several 
months  to  one  or  two  years.  With  delicate  children  it  is  not 
only  desirable,  but  necessary,  that  they  should  enjoy  the  hygienic 
and  climatic  advantages  of  mineral  and  sea  sanatoria  for  several 
years.  But  joined  to  this  there  is  the  justifiable  objection  that 
such  children,  in  the  years  when  they  are  most  capable  of  develop- 
ment, are  removed  from  their  school  education  and  fall  behind 
their  companions  of  the  same  age.  It  is  therefore  a  pressing 
necessity  that  there  should  be  provided  a  larger  number  of  such 
institutions  in  which  regular  instruction  can  be  given. 

The  combination  of  the  treatment  wath  instruction  is  also 
desirable,  and  even  demanded,  for  psycho-therapeutic  reasons,  for 
the  child  should  not  think  about  its  disease  more  than  is  absolutely 
necessary.  He  should  not  be  conscious  that  his  development  is 
different  from  that  of  other  children,  so  that  the  mark  of  a 
separate  existence,  a  special  bodily  inferiority,  and  special  need 
of  care  should  not  be  stamped  on  his  impressionable  nature,  as 
this  may  have  an  adverse  influence  on  him  for  his  whole  life. 

We  have  already  emphasized  elsewhere  the  enormously 
beneficial  arrangement  of  forest  schools  (see  p.  319). 

Up  to  the  present  we  know  of  the  following  school 
sanatoria  :  — 


3bo 


SCROFULOSIS 


(A)  In   Inland  Places. 


Number  and 

, 

-Age  of 

PLice 

Sort  of  Instruction. 

Price                1 

Scholars. 

Boys 

Girls. 

Open-air    School,     Hohenlychen 

Instruction  in  house- 

_ 

in  the  Uckermaik 

keeping  and  garden- 

Agnetendorf in  the  Riesengebirge, 

ing 
High  School  subjects 

— 

6 — 12 

6—20 

Elise  I  loningers  boarding  school 

National     School 
teaching,    house- 
keeping 

Bad  Berkain  Thi'iringia  ... 

'  "  Kealschule"  Pro- 

1, 800    M.   inclu- 

For boys 

gymnasium,      Real- 

ding  board  and 

gymnasium 

instruction 

Triiper's  Educational  Home  and 

Reform     School     to 

About   eoo  i\r. 

In     separate 

Sanatorium  for  the  young,  Jena 

lower  second  class, 

per  ^  year 

houses  each 

house      -      keeping 

12—16  pu- 

school for  girls,  ele- 

pils 

mentary      practical 

branches,      garden- 

ing, &c. 

Haus   Bartelsruh,    Lauterberg  in 

"Kealschule" 

— 

— 

— 

Hesse 

Private  Childrens  Home.     Roth- 

School  in  ihe  Institu- 

5 M.  per  day 

engeldeSpa,  in  theTeutoburger 
Forest 
Michendorf   Children's   boarding 

tion 

Individual       instruc- 



school,  nr.  Berlin 

tion  and  education 

School     Sanatorium,     Friederici- 

Elementary     classes, 

2,500—3,000 

anum,  Davos- Platz,  Switzerland 

lower  classes,  6th — 
1st  classes,  Real  and 
Gymnasium  classes 

Fr. 

School    Sanatorium,    U.    Aegeri, 

Instruction    for 

160 — 250  Fr.  per 

Canton  Zug,  Switzerland 

people's  and  middle 
schools 

month,     accor- 
ding to  instruc- 
tion 

(B] 

On  the  Sea  Coast 

School      Sanatorium,      Borkum, 

Curriculum      up 

to 

1,480  M, 

1 
For  65  boys 

North  Sea 

upper  2nd  class 
elusive 

in- 

Dr.  Gmelin's  North  Sea  Pedago- 

Progymnasium 

and 

800  M.  for  term 

For  100  boys 

gium,  Fohr 

"  Kealschule" 

(4   months)    in- 
cluding   board, 
instruction  and 
treatment 

and 

jirls 

North    Sea   School    Sanatorium, 

Up  to  1st  class 

150 — 210  M.  per 

For  boys   of 

Westerland-Sylt 

month,     exclu- 

5— 1 8  years 

sive  of  instruc- 

and 

girls 

tion 

Martha  Elsehaus  Children's  Nur- 



— 

14 

18 

sing  Home,  Swinemlinde,  on  the 

Baltic 

Hubertusberg  Private  Home  for 

Private  School 

— 

6-15 

6-16 

Children,    Zinnowitz,    on     the 

Baltic 

Holiday  Settlement,   Liibeck,   on 

— 

Free 

100 

the  Privall,  nr.  Travemimde 

10—14 

Forestry,  Mellneraggennr.  Memel 

24 
6 — 14 

1  Gymnasium  =  belter  class  school,   in  which  classics  are  taught.     Kealschule  =  high  school,  in  which 
modern  languages  are  taught  instead  of  classics. — Translator. 


THKRAPFJJTICS 


361 


H.     RESULTS  IN   MINERAL  AND  SEASIDE 
CONVALESCENT  HOMES. 

The  cures  wliicli  have  been  made  in  mineral  and  seaside 
homes  are  all  I  lie  more  valuable  as  statislics  relating  t(j  the 
possibilily  ol"  curing  scrofulosis  have;  hitherto  been   wanting. 

We  take  a  few  records  from  (he  statements  of  some  conse- 
cutive periods  :  — 


percentage  of 
Cures  I    Improvement* 


Mineral  Baths. 

Sulzbach'  ... 

Hall,"  i8';6— 1896  

Hall,-'  1856— 1896  

1896— 1906  

Jagstfelcl,'i86i  — 1876,  1878     

Jagstfeld,'' 1876  and  1878  

Seaside  Places. 

S.  Pelagio,"  1888— 1898     

Rovigno,  1898 

Berc-sur-mer,'  1869 — 1882    

Refsnas  ... 

Norderney,  1882 — 1883      

Norderney,  1882— 1884 

Wyk,  1882— 1884 

Gr.  Miiritz,  1880— 1884  

Lido 

Porto  d'Anzio 

Margate,"  1876— 1878 

Fano,  Rimini,  Sestri" 

Venice  (Ospizio  Marino,'"  1S68— 1879 

Voltri,  1865—1875  

Palermo,  1874 — 1876      

Loano,  1872— 1S75         

1878  


610 

789 

7.147 

63-0 

332 

10,219 

46-2 

51  0 

4.578 

68-2 

295 

3,102 

i6-6 

646 

416 

91 

71-1 

1. 945 

68-2 

— 

442 

71-5 

i8-6 

4,962 

707 

3'2 

499 

44  3 

50-5 

175 

37-1 

1 

57-1 

297 

93-3 

254 

957 

108 

96-3 

9,686 

343 

60-4 

5.271 

15-6 

79-2 

883 

68-6 

27-3 

1,623 

64-2 

25-1 

7,277 

370 

58-3 

1,578 

34 

65- 

499 

52 

47 

1,084 

47 

48 

406 

24 

50 

1  According  to  Monti. 

-  Only  scrofulous  patients,  those  treated  several  times  only  counted  once. 

■*  All  taken  in  are  counted. 

■*  According  to  UfFelmann. 

"  Only  scrofulous  patietits. 

8  According  to  Monti. 

"i  According  to  Brauer. 

8  According  to  Uft'elmann.     The  total  of  cured,  improved,  and  not  improved,  &c. ,  838. 

9  Cured  and  considerably  improved. 
1^'  Inclusive  of  those  only  bathing. 


I  cannot  concur  in  the  concUisions  frequently  drawn  from 
some  of  these  records;  the  figures,  for  several  reasons,  must  be 
accepted  with  caution.  For  one  reason,  in  many  of  these  institu- 
tions the  numbers  include  syphilitic,  rickety  and  anaemic  children, 
even  if  only  a  small  proportion  ;  as  long  as  an  exact  separation  is 
not  possible,  the  percentage  of  cures  cannot  be  strictly  identified 
with  the  idea  of  cures  of  scrofulosis. 


362  SCROFULOSIS 

Again,  the  patients  in  different  institutions  are  not  alike  in 
the  form  and  severity  of  their  scrofulosis ;  a  hospital  with  a  sur- 
geon at  its  head,  and  therefore  with  many  severe  surgical  cases 
in  the  third  stage,  naturally  cannot  show  such  good  results  as 
one  with  chiefly  slight  cases ;  a  conclusion  cannot,  therefore,  be 
drawn  as  to  the  capabilities  of  the  institution,  or  the  place,  or  the 
methods. 

Also  the  division,  according  to  age,  which  is  not  without 
influence  on  the  total  result,  differs  according  to  the  rules  re- 
specting the  admission  into  different  institutions. 

The  nursing,  the  possible  and  real  length  of  the  stay,  and 
using  to  the  full  the  factors  for  cure,  are  different.  Some  institu- 
tions are  provided  with  all  medical  and  hygienic  comforts,  others 
must  do  the  best  they  can  with  what  is  strictly  necessary.  As  I 
have  proved  in  a  tour  undertaken  to  study  this  question,  suffi- 
cient attention  is  not  p§iid  everywhere  to  spending  a  long  time 
in  the  open  air.  To  draw  comparisons,  in  spite  of  this,  from  the 
mere  figures  of  the  total  results  between  certain  institutions  or 
between  mineral  and  sea-bathing  places,  betrays  ignorance  of  the 
fundamental  rules  of  statistics. 

A  better  foundation  for  statistical  comparisons  is  offered  by 
the  records  which  classify  scrofulosis,  according  to  the  form  it 
takes ;  individualizing  statistics  may  become  especially  valuable 
with  the  accumulation  of  material,  in  which  each  case  is  shortly 
described,  on  a  few  important  points,  such  as  the  excellent  records 
kept  in  the  institutions  of  Pelagio  and  Sulzbach,  which  were 
initiated  and  conducted  by  Monti. 

On  the  following  page  we  give  the  percentages  of  cures. 
The  figures  do  not  in  the  least  pretend  to  be  scientific  statistics, 
but  onlv  present  a  general  view  of  the  cures  in  different  scro- 
fulous affections ;  foundations  are,  up  to  the  present,  wanting  for 
statistics  free  from  all  objection  and  drawn  up  from  a  large 
number  of  figures. 

It  is  a  pressing  necessity  that  all  hospitals  should  arrange 
their  statistics  and  annual  statements  on  a  plan  in  which  the 
chief  points  and  details  correspond,  as  has  been  done,  for  instance, 
in  the  before-mentioned  institutions  of  Pelagio  and  Sulzbach,  for 
years,  so  that  valuable  statistical  material  may  not  be  lost,  but  by 
being  summed  up  may  afford  large  and  useful  figures  which  will 
enable  comparisons  to  be  drawn.  With  the  exception  of  the  small 
number  of  separate  affections  which  are  subject  to  chance,  statistics 
of  cures  will  always  suffer  from  the  fact  that  certain  authors  give 
to  the  conception  of  "  cure  "  a  hazardouslv  subjective  expansion 
and  talk  of  curing  catarrh  of  the  apex  of  the  lung   ( !)   in  33, 


TMKKAPKU'I'ICS 


363 


(The  upper  fif^urcs  t,'ivc  tlic  nuinbcr  tnialcd,  Uj 


l|]'l.:r   Ir 


"■  I" 


c 

a 

u  h 
■B  3 
m  a 

31.- 

_o  0 

is 

CO 

9 

13 
a 

X. 

3 
0 

[3 

2 
0 

Affcctionii  o« 

•a 
1 

S3 

a 

1 

1 
\ 

1 

,i2 

1 

1 

g 

.S.2, 

_s 

c 

z 
g 

s 

3 

0 

3 

w 

Glandfi 

1 

2 

'I 

"a 

R 

X 

■3 
•i. 

3 

H 

c 

11 

1 
5 

Skaside  Bathing  Places. 

S.  Pelagio 

123 
78-9 

91 

78 

123 
87 

5 
80 

40 
90 

290 
85-2 

230 
817 

30 
733 

622 

6o-6 

137    132 
336  36-4 

122 

599 

' 

54 

53 

29 

I33« 
8ro 

357   3'^i 
36-3  551 

Sestri  Levante 
Bercsur-Mer          

4( 

3 
137 

35 

21 

r267                  ;          ri86 
67-6                              10 

Venice         

462 
53 

2 

0 

Loano 

Banyuls  1888— 1896 

94 

7 

34 

28 

51 
41 

13 
31 

7 
•4 

40 

25 

• 

38 
13 

60 

• 

7o"o 

86-3 
47-0 

95 
35-8 

2  French  hospitals  (Leroux' 

680 

10     French      hospitals 

52-0 

(Armaingaud) 
Fredrikvaern    (Sinding- 
Larsen) 

89 
831 

Windau  (Hopfenhausen) 

3' 
38-5 

25 
44-0 

Mineral  Bathing  Places. 

Sulzbach 

{ 

i8S 
92-4 

169 
6S 

133 
827 

II 

90-9 

38 

1380 
597 

1113 
74-1 

57 

265 
69-8 

230 
89-4 

5° 
90 

1987 
76-2 

1787 
85-1 

180 
4I-I 

145 
51 

8 
100 

72 
84-6 

61 
83-6 

18 

3 

667 

95 
71-6 

i  28 
I25 

35 
84-9 

62 

72-6 

Rivanazzano           

33 

28 

Hall 
(AH  received) 

2073 
42-2 

35S7 
1                      ~'^'~ 

Those  treated  several  times 
only  counted  once 

1550 
56-8 

2147 
42*2 

High  levels. 
Leysin 

01 

364  SCROFULOSIS 

48,  60  days!  A  tirm  grasp  of  this  conceplion  is  a  sine  qua  non 
for  statistics  that  are  to  be  of  any  use. 

Another  difficulty  in  drawing  comparisons  arises  from  the 
very  different  length  of  the  duration  of  the  treatment. 

Some  institutions  can  extend  the  treatment — from  a  medical 
point  of  view  the  only  proper  treatment — according  as  they  think 
it  is  necessary  or  that  there  are  hopes  of  improvement. 

On  an  average  in  Hall  (Upper  Austria)  ihc  treatment  lasted 
66  or  50  days  (1856  to  1895);  in  Sulzbach  (1897),  96  days;  (1898), 
89  davs;  for  many  children,  702,  858  or  949  days,  and  so  on;  in 
Pelagio,  for  the  cured,  100,  or  300  to  500  days;  in  the  greatly 
improved,  20  to  100  days;  for  many  children,  488,  531,  556,  and 
612  days,  &c.   In  Berc-sur-mer  (1869  to  1882),  on  an  average  in  :  — 

Multiple  affections  562  Affections  of  the  hip-joint        ...  426 

Affections  of  the  knee-joint      ...  54J1                ,,             ,,  ear       ...         ...  422 

,,       wrist 488  ,,  ,,       skin      416 

,,       bones 482  ,,  ,,       eyes     405 

,,       ankle-joint    ...  471                ,,             ,,  elbow-joint    ...  370 

,,       vertebrae         ...  470  Ozjena         ...  ...         ...         ...  354 

,,       shoulder-joint  462  Lymphadenitis  ...         ...         ...  342 

Other  institutions  only  keep  the  children  four  to  six  weeks, 
and  naturally  achieve  less  good  results,  though  the  work  is  none 
the  less  valuable. 

A  better  judgment  as  to  the  success  of  the  cures  may  be 
formed  by  comparing  the  time  of  treatment  in  the  following  table 
wdiich  I  have  drawn  up  from  Haberlin's  records. 

Neither  from  these  tables  nor  from  any  other  records  we 
possess  can  it  be  shown  in  a  conclusive  manner  that  mineral  or 
sea  baths  are  more  efficacious,  one  than  the  other,  in  combating 
scrofulosis,  or  that  either  merits  preference.  It  must  be  stated 
with  reference  to  this  that  on  both  sides  an  unwarranted  local 
patriotism  is  displayed  in  the  many  attempts  to  prove  one  more 
efficacious  than  the  other. 

For  instance,  when  Haberlin  in  a  table  {loc.  cii.,  p.  97) 
contrasts  85  per  cent,  cured  in  seaside  hospitals  with  23  per  cent, 
cured  in  mineral  bath  stations,  even  if  he  acknowledges  on  the 
next  page  that  the  usually  longer  stay  in  seaside  hospitals  must 
be  taken  into  account,  there  is  an  evident  source  of  error,  for  to 
avoid  a  false  interpretation  he  should  properly  have  added  that  in 
mineral  bathing  places,  to  achieve  cures  of  about  30  per  cent., 
the  patients  with  scrofulous  affections  of  the  skin  had  only  been 
treated  for  30  davs,  whilst  the  cures  of  about  8  per  cent,  achieved 
in  seaside  places  took  over  400  days,  therefore  were  treated 
thirteen   times  lonorer. 


THERAPEUTICS 


3<^5 


RESULTS  ACCORDING  TO  DURATION  OF  TREATMENT 
Organs  ok  Skin  and  Sknsk. 


Disease 


Is 


8  8 
at. 


Place  of  trcalmenl 


Scrofulous  Eye  and  Ear  Affeclions  ... 
Slcin  and  Mucous  Membranes 
Skin  and  Eye  Affections 
Skin,  Mucous  Membranes,  &c. 

Conjunctivitis,      Lichen    Scrofulosus, 

Otitis  media 
Prurii:;i,   Tul)ercid.  cutis,    Scrofulosis 

of  Ears  and  Nose 
Scrofulosis 

Lupus,  Keratitis,  Otitis,  Skin  Ab- 
scesses, Scrofulosis 

Eye  Affections,  lymph.  Keratitis,  Ble- 
pharitis, mostly  simultaneously  witii 
Rhinitis,  Pharyngitis  and  slight 
Glands 

Lupus,  Prurigo,  Eczema  with  Tuber- 
culosis, general  Scrofuloderma, 
Psoriasis 

Skin,  Mucous  Membranes,  Eyes,  Ears, 
Nose,  Lupus,  Eczema,  Tubercular 
Ulcerations 

Eczema,  I^upus  Vulgaris,  Scaly  Skin 
Ulcers 

Eczema  with  deep  affections  of  Skin 
and  Mucous  Membranes  and  swel- 
lings of  the  glands,  various  affections 
of  the  skin 

Eczema,  Eyes,  Ears,  Nose,  Pharynx, 
Lupus,  intra- muscular  Tuberculosis 

Ozrena   ... 

Skin  Scrofulides,  Mucous  Membranes, 

Nasal  Pharynx,  Eyes,  Ears 
Skin  Scrofulides,  Lupus 

Otorrhoea 


607 
202 

31 

740 

33 
102 

30 

66 

263 


60 

1905 
13 

178 
II 

106 
33 


28 

30 

4S 

60 

56 

93 

114 

120 

132 


i8-8 

297 
677 
71  "O 
637 
56-3 

787 


164    96-8 


213 

264 
265 


777 
607 
32 
24-0 
14-8 
34-6 
90 
33 


90*0      — 


923 
85-0 


275  837 
354  \  54-5 
413  61 -o 
416  '  78-0 
422     73-0 


6-3 


6-0 
9-0 

25-0 
3-0 

120 


Sooden  on  the  Werra 

(Sippel) 

Diirkhcim  r^n  the  Ff. 

(Kaufmann) 

Celle  Ligiiria 

(Bertarelli) 

Wvk 

(Ilabcrlin) 

Sulzbach-Ischl 

( Prochaska) 

Sophia-Stichting 

(.Mol,  1907-08) 

Katwijk 

(D.  V.  Dorp,  1908) 

Sahlenburg 

(Treplin) 

San  Pelagio 

(Monti,  1888— 1906) 


.San  Pelagio 
(Monti,  1888-1906) 

Juelsminde 
(Hoff-Hansen) 


Refsnas 

(Schepelern,  1875  — 1907) 

Berc 

(Cazin) 


Friedriksvaern 

(Sinding-Larsen) 

Berc 

(Cazin) 

10  French  Sanatoria 

(Armaingaud,  1887 — 1905) 

Berc 

(Cazin) 

Berc 

(Cazin) 


Glands 

Scrofulosis  of  the  Glands        

212 

28 

217 

74-=i 

Sooden  on  the  Werra 

Scrofulosis  of  the  Glands 

283 

28 

9-S 

8s-8 

(Sippel,  1905— 190S) 
Diirkheim  in  the  Hardt 

Scrofulosis  of  the  Glands       

20 

91 

6o-o 

SS-o 

(Haufmann,  1902— 1908) 
Sophia-Stichting 

Scrofulosis  of  the  Glands       

69 

100 

S6-2 

4  "9 

(Mol.  1907— 1908) 
Sulzbach-Ischl 

Swelling  of  the  Glands           

550 

115 

98-5 

0-2 

(Prochaska,  1907— 1908) 

San  Pelagio 

(Monti,  1888— 1892) 

1906 — 1908) 

366 


SCROFULOSIS 


Glands — continued 


1 

•5 

•r;  V 

•a 

Disease 

o 

a 

Place  of  treatment 

,0 

n  S 

"2 

e  s 

3 

3 

»  □. 

15 

< 

0 

Tuberculosis  of  Cervical  Glands 

33 

120 

83-0 

10 

Sahlenburg 
(Treplin,  1907— 1908) 

Scrofulosis  of  the  Glands       

118 

'ilU 

72-0 

260 

Berc  Hopit.,  iMar. 
(Bergeron,  1 861— 1868) 

Scrofulosis  of  the  Glands       

120 

261 

71 '0 

2ro 

Fredriksvaern 

(Sinding-Larsen) 

1892— 1900) 

Glands  of  Neck  and  Lower  Jaw,  mul- 

1293 

335 

76-0 

3-0 

Berc  Hopit.,  Mar. 

tiple  glandular  swellings 

380 

68-4 

3-0 

(Cazin,  1885) 

Scrofulosis  of  the  Glands        

105 

338 

9-00 

"  ' 

Juelsminde 
(Hoff- Hansen,  1907 — 1908) 

Swellings   of   the   Lymph    Glands  of 

— 

345 

74  "o 

25-0 

10  French  Homes 

neck  and  back  of  neck 

(Armaingaud) 

Swelling  of  the  Lymph  Glands 

1482 

449 

75-4 

Berc  Hopit.,  Mar. 
(Cazin,  iSSq) 

Swelling  of  the  Lymph  Glands 

320 

479 

cured 

192 

im- 
prove- 
ment 

SB 

same 
con- 

75-0 

i8-o 

2  French  Homes 
(Leroux) 

dition  1 

Bones  and  Joints 


Tuberculosis  of  Bones,  Cartilage  and 

141 

28 

17-0 

83-0 

Sooden  on  the  Werra' 

Joints 

(Sippel) 

Diseases  of  Bones  and  Joints 

192 

ii8 

21-4 

64  "I 

Durkheim  in  the  Hardt 
(Kaufmann) 

Diseases  of  Bones  and  Joints  . . 

253 

91 

707 

IO-3 

Fredriksvaern 
(Sinding-Larsen) 

Coxitis 

89 

91 

83-1 

2-2 

Fredriksvaern 
(Sinding-Larsen 

Various  Caries,  Coxitis,  Gonitis 

"5 

247 

Abt. 

41-9 

7-8 

Sulzbach-Ischl 
(Prochaska) 

Fungous  Joints 

95 

3U0 

71-6 

i6-8 

San  Pelagio 
(Monti) 

Ostitis 

159 

316 
562 

71-1 

16-4 

2  French  Homes 
(Leroux) 

Coxitis,    old  suppurating  fistulns  with 

301 

335 

ss-i 

i8-6 

San  Pelagio 

caries  of  the  heads  of  the  joints 

(Monti) 

Tumour  albus  ... 

137 

419 
724 

56-9 

24-1 

2  French  Hospitals 
(Leroux) 

Affections  of  Bones  and  Joints 

1117 

462 

637 

5-1 

Refsnas 
(Schepelern) 

Malde  Pot        

95 

466 

25-3 

2  French  Hospitals 

971 

35-8 

(Leroux) 

Coxalgia 

IIS 

547 

— 

23 '5 

2  French  Hospitals 

829 

45-2 

(Leroux) 

1  Severe  cases  not  accepted. 


TUIiKAl'KUTICS  3^J7 

l'"urtlier,  wc  sec  ch-arly  fi-(^iii  ilic  I;i1j1i:,s  ili.-ii  ilic  longer  ilie 
treatment  ccjnlinucs,  so  inucli  llie  inoic  considerably  docs  the 
percentage  ot  cures  rise.  All  experienced  piiysicians  agree 
unanimously  that  with  a  short  course  of  four  to  six  weeks  it  'S 
only  in  the  rar(;st  ciises  tiiat  anytliing  satisfactory  or  lasting  can 
be  acliieved,  eilluM-  in  a  mineral  or  sea  bathing  place.  Tiie  looks 
may  be  improved,  llie  vveiglii  increased;  but  as  a  rule,  when  the 
children  return  to  their  unhygienic  and  wretched  conditions  >( 
Hfe,  that  which  has  been  gained  is  soon  lost. 

"  The  child  returns  to  the  hospital  the  following  year,"  says 
Spitzmiiller,  "  more  wretched  and  worse  than  it  ever  was.  Fresh 
ulcers  form  on  the  margins  of  the  old  scars,  fresh  suppuration, 
fresh  swellings  of  the  glands,  operations  are  again  performed  and 
physic  administered — a  discouraging  labour  of  Sisyphus — the  real 
difficulty  of  our  professional  work." 

This  unsatisfactory  limitation,  which  in  cases  that  are  at  all 
severe  cannot  lead  to  thorough  and  lasting  success,  is  often  the 
doctor's  compromise  with  the  gratification  of  the  philanthropists, 
who  open  their  pockets  so  much  more  willingly  when  they  see 
many  children  sharing  the  benefits,  many  cured  (  !). 

The  restriction  is  not  only  sad  for  the  children,  but  also  from 
a  purely  financial  point  of  view  very  serious,  for  when  the 
apparent  gain  has  passed  off  there  is  seen  to  be  no  return  for  the 
expense  incurred  during  the  short  treatment,  and  the  money  is 
partly  thrown  away  (see  also  Salge,  Lennhof,  Wluitbeck  and 
Spitzmiiller).  We  doctors  must  therefore  educate  the  people  up 
to  the  idea  that  the  treatment  is  not  to  be  carried  on  to  satisfy  the 
philanthropist's  love  of  fame,  but  for  the  immediate  need  of  the 
poor  sick  children. 

A  definite  rational  struggle  against  tuberculosis  and  scrofu- 
losis  makes  it  the  bounden  duty  of  every  large  municipality  not 
only  to  choose  one  or  other  of  the  means  of  combating  the  disease, 
but  by  all  the  different  means,  such  as  milk  provision,  care  for 
mothers  and  infants,  creches,  kindergartens,  forest  recreation 
places,  forest  schools,  mineral  baths,  or  seaside  hospitals  to  be 
prepared  to  meet  the  requirements,  which  are  often  widelv 
different,  so  as  in  each  case  to  be  able  to  follow  the  method  of 
treatment  promising  the  greatest  success,  and  therefore  the 
method  which  is  financially  the  most  profitable.  Small  towns 
must  band  themselves  together  for  this  end,  so  that  money  shall 
not  be  needlessly  wasted  or  (which  is  more  to  be  feared)  that 
nothing  may  be  done. 

In  Germany,  the  Government  authorities  for  Home  affairs 
have  repeatedlv  proclaimed  that  the  public  care  of  the  poor  is  one 


368  SCROFULOSIS 

of  the  tasks  which  iheir  position  imposes  on  them  :  to  give  to 
children's  hospitals  that  form  of  care  which,  in  the  opinions  of 
the  doctors,  is  the  acknowledged  necessary  means  of  treatment 
(Lohse).  French  law  gives  a  similar  power  for  placing  such 
patients  in  instittitions  (Haberlin).      In  Austria  no  such  law  exists. 

I.— SALT  BATHS  AT  HOME. 

If  a  patient  cannot  leave  his  home  to  visit  a  mineral  or  sea 
bathing  place,  salt  baths  in  the  house  may  be  resorted  to  as  a 
makeshift.  It  is  uncertain  whether  these  artificial  mineral  and 
sea  baths  are  equivalent  to  the  natural  baths  in  their  pharmaco- 
dynamic effect;  therapeutically  their  effect  is  not  nearly  the  same. 
Their  inferiority  is  partly  due  to  the  faulty  manner  in  which  they 
are  administered,  and  to  the  conduct  of  the  patient  and  insufficient 
care,  in  consequence  of  which  we  find  the}'  are  more  exhausting, 
but  chiefly  to  the  want  of  other  factors,  the  combination  of  which 
so  considerably  increases  the  effect  of  the  baths,  vis.,  removal 
from  the  usual  environment  and  a  lengthened  stay  in  pure  good 
air,  the  change  of  climate  and  diet,  &c.  The  importance  of  these 
factors  goes  so  far  that  patients  whose  home  is  in  a  mineral 
watering  place  are  sent  to  others,  for  it  is  a  lesson  we  have  learnt 
bv  repeated  experience  that  in  strange  places  much  better  success 
can  be  attained  than  in  the  accustomed  home  surroundings. 

For  the  preparation  of  artificial  baths,  bath  salts  from  the 
different  mineral  springs  which  are  sold  are  added  for  the  ordinary 
warm  bath  water.  Of  these,  preference  is  given  bv  many  to  those 
rich  in  chloride  of  sodium  and  chloride  of  magnesium,  for  reasons 
given  on  p.  332.  Also  those  of  Arnstadt,  Kreuznach,  Oeyn- 
hausen,  Reichenhall,  Salzuflen,  Wittekind,  and  others.  Sea-salt, 
salt-cake,  and  the  cheap  Abraum  salt  of  Stassfurt,  as  well  as  the 
dear  and  inconvenient  mother  lyes,  are  also  used. 

The  quantity  of  salt  added  is  regulated  according  to  the 
concentration  desired ;  to  decide  how  many  kilograms  of  bath 
salts  must  be  added  to  make  the  bath  the  required  strength,  mul- 
tiply the  quantity  of  litres  which  the  bath  holds  by  the  figure  of 
the  desired  percentage,  and  divide  by  100,  e.g.,  if  we  wish  to 
prepare  a  3  per  cent,  bath  in  a  bath  containing  350  litres,  ^^^ox s 
or  io'5  kilograms  bathing  salts  are  necessary.  If  we  wish  to  add  a 
mother  lye,  we  reckon  to  every  kilogram  of  salt  three  times  the 
quantity  of  about  30  per  cent,  mother  lye. 

For  the  mode  of  use  of  artificial  baths,  the  strength,  duration 
and  number,  the  same  rules  apply  as  for  natural  baths  (see  p.  338), 


'1  iii;kai'i;ijii(:s  3^9 

llie  proper  (jiianlily   luiisl,  !)<•  jii<l^«-<l   by  exact  ohsf-rval  ion   ot    ili'-. 
patient. 

Carbonic  acid  hallis  may  be  |)rcparc(l  al  honx-  JKj.ording  lo 
the  method  of  Zucker,  Sedbl/ky,  and  oilu-.rs,  but  iliey  do  not 
contain  so  much  (X).  as  in  the  bathing  estabbshmenls  or  spas, 
where  they  are  mostly  prepared  acrordin^^  to  Keller,  Raydt,  and 
Kiefer. 


24 


CHAPTER    II. 

MEDICINAL  TREATMENT. 


IODINE. 


Amongst  inu-rnal  remedies  (if  we  except  cod-liver  oil,  which 
we  have  come  to  know  more  as  an  auxiliary  ot  nulrition  than  as 
a  medicine)  iodine  lakes  the  first  place. 

It  is  suitable  for  the  phlegmatic,  relatively  strong  flabby 
children,  and  especially  tliose  suffering  from  scrofulous  glands, 
whilst  for  thin  children  with  larger  tuberculous  foci  it  may  easily 
be  harmful ;  the  excessive  value  attributed  to  ii  in  former  times  is 
due  perhaps  to  the  frequent  mistaking  of  hereditary  syphilis  for 
scrofulosis ;  in  the  former  disease  it  was  certainly  most  successful. 

In  cases  of  disordered  digestion  and  nutrition,  and  with 
symptoms  of  iodism,  cold  in  the  head  and  iodine  conjuncti\itis, 
it  must  be  discontinued;  if  strong  doses  (^f  iodine  be  given  there 
must  be  intervals  in  the  treatment  from  time  to  time. 

The  natural  remedies,  though  weakest  in  iodine,  are  the 
mineral  waters  containing  iodine,  which  are  not  only  drunk  at 
their  source,  but  are  also  exported  (see  p.  341)- 

The  artificially  prepared  iodine  soda  salt  solution  (with  i'3 
iodine  soda),  and  iodine  lithium  solution  (with  0*9  iodine  soda)  in 
one  litre,  prepared  by  Ewich,  contains  more  iodine. 

Iodine  is  also  given  according  (o  the  old  prescription  of 
Lugol  in  three  solutions  : — • 

Iodine 

Potassium  iodide   . 

Distilled    water 

M.D.S.  At  first  two-thirds  are  to  be  taken  daily,  later 
the  entire  solution ;  immediately  before  use  to  be 
sweetened  with  sugar.  The  weakest  solution  is  to  be 
taken  for  the  first  two  weeks,  then"  the  medium  solution, 
for  about  four  weeks,  and  later,  if  necessary,  the 
strongest  solution. 

Tile  following  prescriptions  are  more  usual  :  — 

B  Iodine     ...          ...          ...             o'3-o"5orR  Sodium   chlorat.         ...  ...  3'o 

Potassium  hydro-iodat.        ...        I'o  Sodium    hydro-iodat.  ...  2"o 

Distilled   water          ...         ...    loo'o  Distilled    water          ...  ...  iSo'o 

Peppermint    water   or    simple  PcjiiTrrmint  water 

syrup             ...         ...         ...     20'o  Simple  syrup              ...  aa  lo'o 

M.D.S.     .V  dessert-spoonful  three  or         M.D.S.      Four  tablespoonfuls  to  be 
four  times  a   day    (Henoch).  taken    daily    (for  poor  practice). 


-Solution  i 

.Solution  2 

Solution  3 

0-045 

o'o6 

0-075 

o*io 

O"  12 

0-I5 

250*00 

250-00 

250*00 

-i  iii:i<Ai'KU'iic.s  371 

l(Klinc  is,  vvilli(nil  doiibl,  ,-i  inosi  \;iiii;il)l(:  r(-inr-(Jy  iii  many 
cases  of  scrofulosis.  In  i(<fnl  \c,-ir.s,  and  for  some  lime  pr'-- 
viously,  especially  favoinahic  a(  i  inn  on  1  iiIm'k  nloiis  proeessr-s  has 
been  iitlribuled  lo  il  (sec  (aniniij.  I  ni mann-l  .conardo  believe 
they  have  d('nionsl  lalcd  spccilK  a(  Hon  (»n  1  nlxTc  iilous  tissue  from 
potassium  iodide  in je(  lions.  Ac.cordin^r  to  Griinbert,^  in  eoii- 
junclion  with  niercuiN  rcconmicnded  by  Avelino  .Martin,  ^ood 
results  are  obtained  in  the  Ircalnicnl  of  affections  of  the  nose  and 
pharynx.  Wright  gives  ooi,:;  mercury  succinamide  thirty  limes 
in  sixty  days,  and  r<'peats  after  a  pause  of  three  weeks  (fourteen 
days  of  this  time  with  potassium  iodide,  .seven  days  without  any 
medicine),  linally  ciianging  lo  half  the  dose. 

The  disagreeable  metallic  lasle,  iIh-  injurions  later  effects, 
such  as  dislurl)ances  of  digestion,  cold  in  ilie  head,  irritation  ol 
the  pharynx  and  rashes,  prevent  its  continued  use.  'lo  a\oid 
these,  or  at  least  to  reduce  them,  organic  combinations  of  iodine- 
have  been  used  in  later  years,  by  which  the  body  is  not  so  quickly 
saturated  and  absorption  goes  on  more  gradually.  These  prepara- 
tions fulfil  their  purpose  in  a  measure.  In  scrofulosis  the  follr»w- 
ing  have  proved  of  value  :  — 

lodomenin  [an  organic  iodo-bismuth  combination  (potassium 
iodide,  o"o6  per  tablet),  highly  recommended  by  Cassel,  Fried- 
mann  and  others,  and  without  dyspeptic  consequences],  for 
older  children  of  6  to  10  years  of  age,  one  tablet  three  times  a  day ; 
for  infants  from  8  to  10  months  old,  half  a  tablet  three  times  a  day. 
lodival  (47  per  cent,  iodine),  o"i  gramme  three  times  a  day,  or  o't, 
gramme  everv  three  hours,  in  tablets.  Combinations  of  iodine 
and  albumin  :  lodoglidine  (an  iodine  vegetable  albumin,  but  not 
very  constant),  in  tablets ;  for  adults,  two  to  six  tablets  (o'os 
iodine) ;  for  children,  half  a  tablet  two  or  three  times  a  day,  half 
to  one  hour  after  meals.  lodalb-acid  (a  preparation  of  iodine 
albumin,  soluble  in  water),  for  adults,  3  to  5  grammes  daily,  in 
wafers;  or  as  tablets,  for  children,  J  to  3  grammes  three  times  a 
day.  The  Eigon  preparations  of  Dieterich,  Alpha-eigonnatrium 
(iodine  albumin  anci  sodium)  and  Beta-eigon  (iodine  peptone), 
both  containing  15  per  cent,  of  iodine,  as  tablets  (0*5  gramme), 
and  especially  with  extract  of  malt  in  three  dilYerent  strengths ; 
weak  (o"oo45  iodine),  medium  (0*045  iodine),  strong  (o'45  iodine), 
in  one  tablespoonful.  Sajodin,  introduced  by  v.  Mehring,  the 
good  effect  of  which  has  often  been  confirmed. 

Todotannate,  in  the  form  of  Nourry's  iodinated  wine  or  svrup 
(one  tablespoonful  contains  0*05  gramme  iodine  and  o'l  gramme 
tannin) ;  for  children,  one  teaspoonful  twice  during  meals.  lodipin. 
introduced  bv  Winternitz  (a  chemical  combination  of  iodine  and 


372  SCROFULOSIS 

sesame  oil,  in  tablets  o"5  [equal  o"ob5  potassium  iodide]  ;  adults, 
two  to  four  tablets  three  times  a  day  ;  children,  ^  to  -J  tablet,  accord- 
ing to  age). 

lodipin  (25  per  cent.)  is  also  used  as  an  intramuscular  injec- 
tion of  5  to  15  c.c.  Personally,  in  two  cases  with  a  gluteal  injec- 
tion of  10  c.c.  after  lengthened  use  in  debilitated  syphilitic  persons 
with  phthisis,  I  have  noticed  that  it  was  not  absorbed,  but  induced 
very  serious  abscesses;  smaller  (.loses  were  in  other  cases  borne 
well. 

Iodine  is  also  given  with  cod-li\"er  oil  (iodine  0*05  with 
30  grammes  cod-liver  oil),  one  to  two  teaspoonfuls  morning  and 
evening,  and  where  anaemic,  chlorotic  and  atonic  conditions  have 
to  be  battled  with  the  combination  of  iodine  with  iron  is  especially 
favoured  (see  below). 

IRON. 

Anaemic  conditions  appearing  before  or  after  scrofulosis  are 
an  indication  for  the  administration  of  iron. 

The  natural  iron  waters — Pyrmont,  0*077  per  1,000  iron  ; 
Driburg,  0*074  per  1,000  iron;  Schwalbach,  o"o84  per  1,000  iron 
— frequently  suit  better  than  all  others  and  are  free  from  dyspeptic 
effects ;  to  preserve  the  teeth  they  should  be  sucked  through  a  glass 
tube  and  the  mouth  afterwards  rinsed.  Salad  and  raw  fruit  must 
be  avoided  during  iron  treatment. 

Of  older  remedies  much  liked  by  children  and  which  are  still 
in  use  I  would  mention  ferrum  lacticum  :  for  instance,  ferri  lactici 
10,  vini  gentian.  600,  Sig.,  a  wineglassful  every  morning  (Jobert 
de  Lamballe) ;  the  tinctura  ferri  pomata  10  to  30  drops  or  more 
daily,  or  ferri  carbon,  sacchar.  5,  pulv.  aerophor.^  50,  one  tea- 
spoonful  three  times  a  day,  or  ferrum  pyrophosph.  o"i  to  o'3  or 
o*6;  also  the  tinctura  ferri  composita  Athenstadt,  for  children,  a 
teaspoonful  to  a  tablespoonful  three  times  a  day  before  food. 

A  very  pleasant  preparation  is  ferrum  cit.  effervescens,  half 
to  one  teaspoonful  three  times  a  day  in  a  wineglass  of  sugar  and 
water  (Ewald). 

A  prescription  much  liked  is  :  — 

E     Lipanin 

Extr.    maltae              ...  ...  ...  ...  aa  5o'o 

Calc.    carb.   praecip.  ...  ...  ...  ...  2"o 

Ferri   carb.    sacch.  ...  ...  ...  ...  5*0 

D.S.     A  teaspoonful  three  times  a  day  (Monti). 
Also  the  liquor  ferri  albuminati,  ^-i  teaspoonful  two  or 
three   times  a  day;   and   the  old-fashioned    Blaud's 
pill  for  bigger  children. 

"  Sodium  bicarbonate  and  tartaric  acid. — Translator. 


TIIKKAI'KIJTICS  373 

Tin:  older  picp.'ir.'il  ions  nl  iron  ollcn  upsii  ihc  sIouk'k  li,  v.iili 
pain  antl  even  sickness  after  a  few  days.  In  n'<;<-nl.  years  iIk,' 
following  iron  albuminous  preparations  have  her-n  niueli  used,  and 
have  the  advantage  of  Ixing  easily  absorbed  .ind  assimilated. 
Fersan  (an  organic  ircjn  pliospliale  prej)ar.-ii  ion;,  half  a  leaspoonful 
twice  a  day,  al  noon  ,'ind  evening,  slirred  inio  inill<,  chocolate  or 
meal  foods,  also  in  paslille.s;  for  (  liildren,  ilirec  lo  lour  jjastilles  of 
0*25  each  (paslillcs  of  o'^  eac  li  lor  adulisj  iliree  or  four  times  a 
day  before  food;  it  is  also  nuicli  liked  in  ilie  form  of  fersan 
malt  extract,  fersan  cocoa,  and  fersan  (  liocolate  pastilles. 
Gehe's  triferrin  (an  organic  c(jmpoiind  of  phosphoric  acid 
and  iron,  according  to  E.  Salkowslii),  in  powders  or  chocolate 
tablets  of  o"3  triferrin,  three  times  a  day  before  or  after  meals,  is 
especially  suitable  in  stomach  affections  on  account  of  its  insolu- 
bility in  the  juices  of  the  stomach;  also  Gehe's  triferrol  (triferrin 
in  solution),  a  teaspoonful  three  times  a  day,  also  very  valuable 
in  lymphatic  constitutions,  according  to  Reichelt.  Klopfer's 
ferro-glidine  (a  compound  of  iron  and  vegetable  albumin),  for 
children  half  to  two  tablets  daily  (each  tablet  containing  0*025  Fe). 
Boehringer's  ferratin,  for  children  once  or  twice  a  day,  for  adults 
three  or  four  times  a  day,  0*5  gramme  in  powders  or  tablets,  or 
(especially  for  children  dissolved  as  ferratose)  one  tablespoonful 
three  or  four  times  a  day  for  adults — children  half  that  amount — 
after  meals. 

Stroschein's  spinol  may  also  be  mentioned  (vegetable  iron), 
5  to  20  drops  three  times  a  day,  for  children  up  to  10  years  of 
age.  Spinolum  siccum,  one  tablet  three  or  four  times  a  day; 
also  DoUes's  aromatic  iron  milk. 

The  folIoAving  are  of  value  :  Gude's  manganese  iron  peptone, 
one  teaspoonful  twice  a  day  for  children  up  to  12  years  of  age, 
diluted  with  milk.  Dietrich's  iron  manganese  preparations  (o'6 
per  cent,  iron,  o'l  per  cent,  manganese),  found  by  Schwabe  very 
valuable,  especially  in  scrofulous  affections  of  the  eye.  Liq.  ferri 
manganese  peptonate,  one  teaspoonful  three  times  a  day  before 
or  after  meals.  Keysser's  liq.  ferro  mangan.  pepton.  given  b\- 
Ascher,  especially  in  scrofulous  eczema  and  enlarged  glands,  one 
teaspoonful  three  times  a  day  in  milk.  Rieche's  mangan.  iron 
peptonate,  one  teaspoonful  three  or  four  times  a  day  in  cold  milk. 
Hasmaticum  (Glausch,  aromatic  iron  manganese  elixir),  one  or  two 
teaspoonfuls  in  milk  three  times  a  day  after  food. 

Of  the  large  number  of  so-called  blood  preparations  which  are 
administered  with  success  in  scrofulosis,  we  will  special Iv  note  : 
H^ematogen  Hommel  :  for  infants,  one  to  two  teaspoonfuls  in  milk, 
not   too   hot;    for   older  children,    one   to   two   dessert-spoonfuls. 


374  SCROFULOSIS 

Sanguinal  (Krewel),  in  use  for  some  years  :  one  to  [\\o  pills  three 
limes  a  clay;  for  scrofulous  glands,  pil.  sanguin.  cum  iodo. 
Bioferrin.  introduced  with  success  by  Siegert  (containing  much 
haemoglobin)  :  5  to  10  grammes  for  a  child  i  year  old,  10  to  20 
grammes  for  a  child  from  2  to  10  years  old.  Bioglobin  (an  iron 
blood  preparation),  one  teaspoonful  three  times  a  day  for  children. 
Perdvnamin  (an  organic  iron  albumin  preparation,  combined  with 
hc-vmoelobin).  luibiose  (a  olycerine-free  concentrated  h:i?mo- 
globin).  Hcunintin  allniniin  (Finsen).  H^emaiopan  (Pfeuffer 
or  Xardi).  Hcumol,  hcemogallol,  ha?matopan  (a  dried  blood 
preparation  with  40  per  cent,  malt  extract).  Roborin  (a  blood 
albumin  preparation).  Sicco  (Schneider),  an  organic  iron  man- 
ganese preparation. 

The  combination  of  iron  with  iodine  is  very  suitable.  The 
syrup  of  iodide  of  iron  is  very  famous  :  — 

B  Syrupi    ferr.    iodidi     15-0    E  Ferr.    pulv i'5 

Syrupi    simpl 5o'o  lodi.    puri 2' 5 

Aeth.    acet To  Aq.    dest.,   gtt.    nonnull.   terc 

M.D.S.     i-i  tablespoonful  three  times  adde 

a  day.  Sacch.    albi 

Sacch.  fact.       ...         ...        aa     2*5 

B  Pot.     iodidi       2"i^  Rad.    alth.   pulv 5*0 

Ferri.    sulph.                2'o  M.  f  pil.  centum,  obduc.  c. 

Morph.   hydrochlor o'o6  Sol.  bals.   tolut.  seth. 

Solve  in  aq.   cinnam.            ...     3o"o  D.S.      1-3   piUs    three    times    a    day 

Liq.    aurant    flor.        ...         ...  20o'o  (Clarus) 

M.D.S.      I   tablespoimful  two  to  three 
times  a  day  (Lcbert) 

Of  newer  preparations  the  following  have  proved  useful  : 
lodoferratin  (Boehringer),  in  tablets,  one  or  two  three  or  four 
times  a  dav,  and  especially  in  the  soluble  form  as  iodoferrato.se 
(o"3  per  cent,  organic  combined  iron,  and  o'3  per  cent,  organic 
combined  iodine),  which  has  done  good  service  in  scrofulosis, 
according  to  the  experience  of  Manasse  and  Bardach  (Kreuznach), 
in  original  bottle,  one  tablespoonful  three  or  four  times  a  day 
after  meals;  half  that  amount  for  children.  Iron  sajodin,  in 
tablets,  one  tablet  three  to  four  times  a  day  after  meals,  or  as 
iron-sajodin  and  cod-liver  oil,  5  to  10  c.c.  three  times  a  day; 
for  adults,  10  c.c.  four  times  a  day  after  meals.  lodofersan,  in 
pastilles  :  for  adults,  six  to  nine  pastilles  a  day  ;  and  for  children, 
two  or  four  a  day  (pot.  iodide,  0*025;  fersan,  0*25). 

Remedies  also  in  use  are  :  Rachisan  (cod-liver  oil,  iodine, 
lecithin,  nuclein,  iron,  mannit),  one  dessert-spoonful  three  times  a 
day.  lodella  (Lahusen,  iodine  iron,  cod-liver  oil),  one  teaspoonful 
after  food,  increasing  to  two  to  three  dessert-spoonfuls  a  dav. 

Tn  the  administration  of  iron  preparations,  as  in  the  use  of 


J  iii:raim;utics  375 

iodine,  grcal  allcniioii  iniisi  lie  |).'ii(l  in  ilic  digestive  (organs; 
generally  they  nnisi  iml  he  taken  on  an  ciniji)'  slomacli,  and  if 
they  disagree  iniisI    he  disconi  inucd. 

ARSENIC. 

Arsenic,  llic  (lid-cslahlishcd  and  iiclpliil  renied)  (;l  (jur  pliar- 
macopLuia,  must  be  used  with  eaulion  in  tuberculosis  and  weak 
conditions;  il  is  mucli  pi'csciibcfl  in  ihi-  torni  <if  tinct.  arsenic 
(Fowler's  scjlution),  which,   however,  ollcn  dof.s  noi   suit  :  — 

li     Liq.    arsenic   Fowler i         ...         ...         ...         ...       5'o 

Tinct.    ferri   pomat.  ...         ...         ...         ...     25'o 

D.S.      5-30  droits  two   or   (lircc   limrs   a    clay,    increasing 

by  degrees  (Lebert), 
Oi'   liq.    i)f)ta.ssii.   arson.   a(|.    rinnam.    aa,   7,-^'  drops  throf 

times  a  day. 

Of  natm-al  arsenical  iron  waters  the  Gubcr  spring  is  especially 
used  (o'37  ferric  oxide  in  o'obi  anhydrous  arsenious  acid  in  1,000 
parts  by  weight  (Ludwig),  rising  from  a  dessert-spoonful  twice  a 
day  to  a  tablespoonful  three  times  a  day,  for  about  six  weeks,  then 
an  interval).  Levico,  Roncegno  and  Diirk-heim  are  also  frequently 
used. 

Disturbances  of  digestion  and  other  toxic  symptoms,  which 
frequently  appear  after  the  use  of  inorganic  arsenical  com- 
pounds, require  correction,  and  this  may  sometimes  be  found  in 
organic  compounds  of  arsenic.  Recently  these  have  been  pre- 
ferred in  conjunction  with  the  arsenical  waters,  so  that  Arsan 
(Klopfer),  a  combination  of  arsenic  with  giidine  (half  to  two  tablets 
for  children  daily  after  meals)  is  recommended.  Each  tablet  con- 
tains o'oo2  arsenic,  combined  with  vegetable  albumin.  The 
combination  of  arsenic  with  the  albumin  preparations  already 
mentioned  is  much  to  be  recommended.  Arsenferratin  (Boeh- 
ringer),  in  tablets  {^  per  cent,  iron  and  o'o6  per  cent,  arsenic), 
one  to  two  tablets  three  times  a  dav ;  and  arsenferratose  (0*3  per 
cent,  iron  and  0*003  per  cent,  arsenic),  iirst  tried  bv  Laquer  and 
Bardach  in  scrofulosis,  one  to  two  tablespoonfuls  three  times  a 
da_y,  half  that  dose  for  children.  Arsentriferrin  (Knoll),  16  per 
'cent,  iron,  o'l  per  cent,  arsenic,  2 "3  per  cent,  phosphorus,  accord- 
ing to  Teubert  especially  useful  in  itching  scrofulous  skin  affec- 
tions, and  in  glandular  swellings  (see  Mosse  and  others),  one 
tablet  three  times  a  day  (one  tablet  contains  o'o^  gramme  iron  and 
0*0003  gramme  arsenic.  Arsentriferrol,  three  tablespoonfuls  three 
times  a  day  (equivalent  to  one  tablet),  for  children  one  dessert- 
spoonful.    I    have   frequently  observed   that    it    suits   well    when 


376  SCROFULOSIS 

Fowler's  solution  and  arsenical  waters  cause  indigeslion.  Arsen- 
regenerin,  arsycodile  clin.  are  other  preparations. 

As  already  mentioned,  we  possess  no  specific  remedies  for 
scrofulosis;  it  is  true  many  have  been  recommended,  but  the 
certainty  of  their  effect  leaves  much  to  be  desired,  and  the  causa- 
tive connection  between  their  application  and  an  improvement  is 
still  neither  assured  nor  explained. 

The  chief  are:  Creosote,  cinnamic  acid,  and  tuberculin.  To 
avoid  repetition  I  shall  limit  myself  to  the  essentials  here,  and 
refer  my  readers  to  my  "  Tuberculose,"  second  edition,  chapter 
on  "  Therapeutics." 


CREOSOTE. 

Of  the  so-called  chemical  remedies  creosote  is  of  chief  impor- 
tance, Sommerbrodt  having  observed  favourable  effects  from  it  in 
pulmonary  tuberculosis,  recommended  it  for  tuberculous  glands, 
and  then  for  all  forms  of  tuberculosis;  he  gave  one  drop  three 
times  a  day  to  children  under  7  years  of  age  in  milk,  rising  J  to 
I  to  I  gramme  daily  in  eight  or  ten  days ;  to  children  over  7  years 
of  age,  rising  to  3  grammes  daily  (capsules,  o"i  creosote,  with 
cod-liver  oil,  not  balsam  of  tolu). 

Although  it  has  not  established  itself  as  an  antibacillary 
remedv  by  my  experiments  on  animals,  I  rely  upon  it  and  its 
derivatives  in  scrofulosis. 

It  has  not  only  very  favourable  action  on  more  than  half  the 
cases  of  catarrhal  conditions  of  the  mucous  membranes,  but 
frequently  exercises  an  undeniably  beneficial  influence  on 
glandular,  bone  and  joint  affections,  besides  -which  it  sharpens 
the  appetite,  often  removes  obstinate  diarrhoea  associated  with 
scrofulosis,  and  furthers  nutrition  generally. 

One  is  best  guided  (as  is  often  the  case  in  medical  matters) 
by  the  success  in  individual  cases.  If  the  scrofulosis  gets  better 
with  the  use  of  creosote,  then  it  is  given  for  a  longer  period ; 
but  if  after  about  two  months  use  there  is  no  improvement,  or 
should  toxic  symptoms  appear  (as  shown  by  the  urine),  or  diges- 
tive troubles,  or  irritation  of  the  kidneys,  the  remedy  must  at 
once  be  given  up,  and  one  of  the  many  derivatives  so  widely 
advertised  may  be  tried. 

Creosote  and  all  its  preparations  should  not  be  taken  on  an 
empty  stomach ;  the  daily  dose  is  i  to  2  grammes,  increasing 
gradually;  in  febrile  cases  o'2  to  0*5  gramme,  or  i  to  2  drops, 
three  times  a  day  in  milk. 


riii:i<Ai'i;i;'i  ics  .377 

IJ  01.    jccor.    aselli  lo'o     l:   ')|.    amyM'i-    du)';. 

I'ulv.    gumnii   ai;i,b.      ...  ...     q.s.  CrcoscjU  ...         ...        aa     15*0 

Acj.   (Icstill.         ...         ...         ...     'j'/o     D.S.     5-)o  drops  two  to  three  times 

a    (lay   in    7,0  ^'''immf-S   nriilk    (van 
Ut.  f.  emulsio  addc  dcr  Vloct). 

Creosoti  I'o-rs     u  Crcosoti       |-o-,-5 

Aq.  menth.  __  (ilyrcrini     Oo'o 

Syr.  simpl aa     s'o         Syr.  riPjis     40-6 

D.S.     J    tablcspoonful    three    limes    a  OI.  month.  gtt.  20 

day   (for  infants — -Monti)  D.S.     2-3   tabicspoonfuls   daily  Ln   a 

glass  of   water. 

Giiaiacx^l  is  now  mcjrc  iisetl  than  crcio.solc,  or  clcrivaLi\f'S  from 
the  Iwo  are  used,  es])ecially  creosoliiin  carhoniciim  (creosotal)  and 
guaiacolum  earbonicum  (Dtioial),  which,  as  a  rule,  are  wfll 
digested,  and  apparenlly  hardlv  (hITci-  from  creosole  in  thera])'-utie 
value. 

li     Guaiacoli    puri     ...          ...          ...          ...          ...  ro-2'0 

Aq.    destill.           iSo'o 

Alcohol                   ...         ...         ...         ...         ...  2o'o 

D.S.  I  teaspoon ful  twice  a  day  in  ;i  glass  of  water 
(Sahli,  Monti) 

Creosotal,  a  viscid,  dense,  }'ellow  fluid,  has  jDroved  itself  of 
much  value  in  the  numerous  experiences  of  the  various  authors. 
Heubner  and  Huht  have,  like  myself,  recommended  it  for  years. 
It  is  given  to  children,  beginning  with  two  drops  and  rising 
carefully  bv  one  or  two  drops;  eight,  and  then .  ten  to  twenty 
drops,  according  to  age  (adults,  2  to  5  grammes  in  gelatine 
capsules)  quarter  of  an  hour  after  meals,  in  warm  sweetened  milk, 
or  in  broth,  or  powdered  sugar,  or  (according  to  Mock)  in  cod- 
liver  oil. 

R  Creosotal  ...         ...  3'o-5"o      B  Creosotal        ...         ...         ...       s'o 

01.   jecor.   aselli         ...         ...     loo'o         Vitelli  ov.  unius 

Saccharini         ...         ...         ...       o'o5_         Aci.    cinnamon  ...         ...     70*0 

D.S.     For  children  under  i  year  o'ls-      D.S.     2-3    tablespooufuls    (children 
o'5o,    also    I    teaspoonful    of    3    per         i    teaspoonful) ;    i    tablespoonful  = 
cent,     to    2    teaspoonfuls    of    5    per         To  creosotal   (Rabow) 
cent,    cod-liver    oil,    older    children 
o'S-i'S  grammes  a  day. 

Sometimes  duotal  (po^vder)  is  digested  better;  for  children 
o"i  (to  o'5  to  o"7)  gramme  three  times  a  dav ;  for  adults  i  (to  2) 
gramme,  gradually  increasing. 

Of  other  derivatives,  eosote  (creosote  valerianate) ;  geosote 
(guaiacol  valerianate),  two  to  fifteen  drops  in  gruel  three  to  five 
times  a  day ;  and  solveol  may  be  mentioned. 

Thiocol,  a  derivati^-e  of  guaiacol  soluble  in  water,  is  much 
liked,  and  I  had  favourable  experience  with  it  in  phthisis  soon 
after  its  introduction,  which  further  use  has  confirmed  (dose. 
3  grammes  three  times  a  dav).     In  practice  amongst  children  it  Is 


378  SCROFULOSIS 

especially  used  for  scrofulous  patients  in  ihc  form  of  sirolin,  which 
tastes  nice  (one  teaspoonful  several  limes  a  clay).  It  is  also 
recommended  bv  vSoltmann,  Salge,  and  many  others.  For  prac- 
tice amongst  the  poor,  Roche's  sulfosole  serves  as  a  substitute 
(sulfcxsoie  creosotsulphacid  potassium),  an  original  bottle  of 
150  grammes  contains  50  grammes  pure  creosote  (for  children,  one 
to  two  teaspoonfuls;  adults,  three  teaspoonfuls). 

The  following  deserve  menticm  :  Bronchitin  (compounded  of 
guaiacol  sulphacid  potassium,  iliicol,  with  extract  of  thyme),  one 
to  three  teaspoonfuls  in  milk  after  meals,  especially  useful  in 
scroftilous  catarrh.  Histosan  (guaiacol-albuminate),  as  syr. 
histosani  one  teaspoonful  three  times  a  day;  or  as  chocolate 
tablets,  four  to  six  daily;  or  as  powder,  o'5  gramme  three  times 
a  dav  ;  children  less,  according  to  age.  (luaiacose  and  guaiacol- 
somatose  one  teaspoonful  after  meals.  Sanginal  pills,  w^th 
guaiacol,  after  Krewel's  prescription. 

OTHER  REMEDIES. 

Mercury,  antimony  (liufeland);  folia  juglandis  reg.  (Negrier) ; 
chloride  of  potassium,  and  chloride  of  barium,  gold  (Prevost, 
Lallemand,  and  Legrand) ;  bromine,  Plummer's  powder  (Lebert) ; 
cinchona  bark,  with  a  little  calomel  (Fothergill,  according  to 
White);  baldrian,  male  fern  and  digitalis  were  formerly  used  in 
scrofiilosis. 

TUBERCULIN. 

Amongst  the  curative  agents  used  to  remedy  the  products  of 
bacteria,  tuberculin  demands  chief  mention  ;  it  is  no  very  pleasant 
task  to  follow  the  changes  in  the  opinions  respecting  this  remedy, 
and  the  constant  expressions  for  and  against  its  use. 

The  large  and  medium  doses  which  were  used  immediately 
after  its  discovery  for  immunizing  purposes  had,  even  in  some 
severe  cases,  incontestably  surprising  effect.  Some  of  my  patients  at 
that  time  (in  the  year  1890)  and  some  whose  disease  was  rather  far 
advanced,  enjoy  to-day,  after  twenty-two  years,  the  best  of  health ; 
amongst  these  I  would  instance  a  Hungarian  official  with  acute 
phthisis,  and  a  temperature  which  for  weeks  stood  at  39°  C,  also 
the  case  of  an  artisan,  and  others.  In  other  cases  the  doses  then 
given  produced  no  improvement;  in  the  rest  they  undoubtedly 
did  harm  to  the  patients,  and  even  led  in  a  few  instances  to  a 
strong  reaction  in  the  foci  in  the  lungs,  with  llic  symptoms  of 
oedema  and  a  rapid  dc^alh. 

In    consr'(|uencf'   of    these   mishaps    luberrulin    treatment    fell 


I  lll'.KAIM.i:  TICS  379 

more  nnd  inoic  iiiio  ilic  I);h  l;.L;rniiiMl,  .'nid  soon  was  almost  com- 
l^letcly  j^-Jvcn  ii|).  DiiiiiiL;  I  Ik-  lasl  lew  years  it  has  goiKt  through 
a  form  of  new  hiilh,  sinrc  (.oci.s(  li,  :\n(\  soon  afifj-,  Bandf;h'(;r  and 
Rocpkc  and  oMicis,  refolded  extcHeni  resnlis  by  die  use  of  very 
small  doses,  increasing;'  \cr\  sInwK  and  a\iiidin^  any  reaction, 
a  melliod  which  iJiederl  and  hdiiiifh  had  a lread\-  adopted  in  the 
first  \-eai"  (if  die  use  of  iuhcK  ulin.  Jusi  as  hiiinerK'  unfavourable 
opinions  prevailed,  so  laiei'  fa\  oinahle  opinions  increased, 
especialK'  .amone-  (he  mecjical  officers  ot  sanaloria,  for  whom  the 
possession  of  a  simple  and  useful  mediod  ol  injf-ction  had  a 
doubly  imporlani  significance  in  response  lo  die  impatience  of 
manv  invalids,  who  miqhl  (hemselxes  help  the  treatment  only  by 
dietinp;  and  rest  for  man\  mondis.  Lcs  extremes  sc  touchent! 
Instead  of  the  mild,  insidious,  refined  method  so  mucli  prized, 
Schlossmann  (|uicklv  resimied  treatment  with  larger  doses,  the 
method  which  had  formerly  lieen  condemned.  He  certainly 
begins  with  small  doses  (jJ,,-,  mg.  and  less),  by  which  in  cases  of 
protracted  reaction  he  continues  for  weeks  to  arri\-e  at  toleration, 
even  for  thirtv  times  the  same  dose,  until  the  bod\-  l^ecomes  accus- 
tonied  to  it,  then  he  rises  to  higher  doses,  and  his  pupils,  Engel 
and  Bauer,  according  to  whom  "  hitherto  a  wrong  path  had  been 
taken  in  the  therapeutics  of  tuberculosis  by  the  use  of  small 
quantities  of  tuberculin,"  did  not  disdain  in  the  further  develop- 
ment of  vSchlossmann's  method  with  children  to  inject  the 
tremendous  dose  of  5  to  20  c.c.  tul^erculin,  which  surpassed  by 
far  the  usual  doses  in  the  era  of  tubercidin,  and  which  later  was 
so  much  condemned. 

Engel  and  Bauer  endeavour  to  defend  their  rapid  increase 
to  large  doses  by  the  fact  that  only  after  the  injection  of  large 
quantities  of  tuberculin  (on  an  a^•erage  o'l  c.c.)  an  intense  anti- 
body formation  takes  place,  which  mav  be  proved  by  complement 
formation  in  the  blood,  in  the  extent  of  which  they  recognize  the 
standard  for  immunization  against  tuberculosis.  Thev  consider 
fever  important  for  immunization,  and  therefore  even  try  to 
provoke  it.  The  formation  of  antibodies  sinks  rapidlv  after  the 
treatment,  but  nevertheless  remains  at  a  relativelv  high  degree  of 
antibodv  content. 

As  showing  success  with  this  method.  Engel  and  Bauer 
mention  that  "certain  forms  at  least  are  quicklv  and  easilv  made 
tuberculin-fast,  and  that  such  children  li\e,  and  by  further  treat- 
ment with  doses  of  i  to  5  grammes  enjov  excellent  health." 

Now  the  theoretical  hypothesis  of  these  proofs  are  of  a  verv 
loose  nature,  for  the  therapeutic  action  of  tuberculin  depends  on 
the  assimilation  of  slowlv  increased  doses,  a  graduallv  attained 


380  SCROiaLOSIS 

insensitiveness  of  the  body  lo  tuberculous  poison,  a  poison-fast 
condition. 

But  it  is  b_v  no  means  pr(>\  ed  thai  this  insensitiveness  to 
tuberculin  goes  liand  in  hand  with  ilic  increase  of  imnume 
bodies. 

Neither  have  we  any  exact  knowledge  of  the  significance 
of  the  connection  of  the  reaction  of  the  formation  of  the  comple- 
ment with  the  ctire  of  tuberculosis,  so  that  Schlossmann's  treat- 
ment cannot  be  sup]3orled  in  this  connection  (Rohmer,  and  see 
further  in  Bibliography).  In  spite  of  the  highest  degree  of 
immunization,  or  poison-fast  state,  a  curative  action  is  in  no  way 
connected  with  it.  For  instance,  in  the  early  period  of  tuberculin 
treatment,  I  had  under  my  care  a  moderately  severe  affection  of 
the  lungs  which,  with  the  exception  of  a  reaction  after  the  first 
injection,  in  spite  of  the  rapid  increase  of  doses,  to  even  i  gramme 
of  pure  tuberculin,  did  not  react  again.  The  j^atient  returned 
home,  to  his  complete  satisfaction  and  my  own,  poison-fast  and, 
according  to  the  point  of  view  of  that  period,  "  cured."  Unfor- 
tunately, a  fortnight  later  I  received  the  announcement  of  his 
death,  and  the  information  that  immediately  after  his  return  home 
he  had  high  fever  (?  miliarv  tuberculosis);  this  undeceived  me 
as  to  mv  supposed  success  in  the  treatment. 

With  respect  to  Schlossmann's  success,  Toeplitz  is  one  of 
the  few  \\ho  begins  with  large  doses,  and  has  seen  success  follow 
them,  remarking  that  the  anatomical  condition  is  less  clearly 
defined,  as  we  frequently  have  to  do  with  tuberculosis  of  the 
bronchial  glands,  which  (being  deep-seated)  cannot  be  physically 
examined,  and  thus  leaves  it  an  open  question  whether  it  is  active 
tuberculosis  which  has  been  treated;  besides,  Schlossmann  in 
the  choice  of  his  cases  relied  chiefly  on  the  v.  Pirquet  reaction, 
which  gives  us  no  sure  indication  of  the  character  and  type  of  the 
infection,  whether  active  or  inactive,  human  or  bovine  (see  also 
Engel  and  Bauer). 

But  w-e  will  let  that  question  rest.  In  any  case  the  further 
tests  by  others  attained  no  results  which  encourage  a  continuation 
of  the  treatment.  Ileubner  gave  up  Schlossmann's  method  after 
a  few  trials;  he  does  not  consider  the  enormous  doses  necessary  in 
scrofulosis,  and  considers  them  highly  dangerous  in  pulmonary 
tuberculosis  {i.e.,  undoubted  tuberculosis). 

Tn  P.  Rohmer's  opinion  the  method  might  be  carried  out,  for 
scrofulous  symptoms  showed  clinical  signs  of  healing  with 
anatomical  proliferation  of  connective  tissue,  but  the  further 
dispersal  of  the  process  was  not  prevented  [was  "  perhaps 
advanced  " — Author],  and  the  general  health  adverselv  affected, 
so  that  for  the  future  small  doses  were  to  be  recommended. 


'iiii;kAi'i:ij']  ics  381 

I'^uclis  <jb.s(M\  (•(!  110  singW:  success  afi'-r  cnijilo)  iiig  Scliloss- 
inaiin's  mclliod,  l)iil  a  |)ailial  aggra\  al  ion  and  cxlcnsion  of  lli<: 
LubercLiloLis  process. 

Hiese  large  doses  vv(;re  ecjnsidf-red  unnecessary  by  decided 
su|)|)oiiers  of  I iibcrcidin,  mm  ii  as  )o(  lini.nin,  who  emphasized  the 
danger  of  .Schlossmann \s  mdhod  ni  pulmonary  tuberculosis. 
Neumann  noted  the  dangers  of  laige  doses  with  focal  reaction 
near  (he  spinal  cord  in  spondylitis,  also  the  appearance  of  seriou.s 
dyspncca  (tubercuhjus  asthma)  which  arose  in  some  cases  of 
tuberculosis  of  the  bronchial  glands,  perhaps  in  consequence  of 
this  focal  reaction  (see  also  Minkowski  and  Czerny). 

Therefore  we,  with  most  other  authcjrs,  must  reject  the  method 
of  Schlossmann  and  Bauer  and  Engel  under  all  circumstances. 

No  conclusive  opinion  as  to  small  doses  is  to  hand.  A 
cautious  tuberculin  treatment  with  only  small  doses  has  in  the 
present  day  found  a  tolerable  number  of  followers  amongst 
physicians,  and  is  considered  by  many  not  dangerous  and  free 
from  any  harm  (Loewenstein,  Weicker,  v.  Ruck,  Saathoff,  and 
many  others).  Whilst,  in  the  Congress  in  Vienna,  most  of  the 
specialists  in  tuberculosis  expressed  themselves  in  favour  of  it, 
especially  after  experience  in  adults,  the  opinions  at  the  French 
Congress  were  very  diversified.  What  caution  it  is  necessary 
to  exercise  in  criticizing  the  success  of  treatment  is  shown  by 
Liidke's  summary,  according  to  which  Moller  in  600  cases 
attained  success  in  36*3  per  cent,  with  tuberculin,  and  with  only 
hospital  treatment  lo'g  per  cent.,  whilst  Schroder,  with  only 
hospital  treatment,  had  40'6  per  cent,  successes.  Klemperer, 
Schelbe,  and  many  others,  come  to  the  conclusion  tliat  certain 
proof  of  the  curative  effect  of  tuberculin  has  not  yet  been  adduced, 
but  Petruschky,  the  indefatigable  champion  of  tuberculin  treat- 
ment, defends  it  energetically,  remarking  that  more  especially  in 
scrofulo-tuberculosis  often  only  a  treatment  by  stages  extending 
over  several  years  (say  twice  a  year,  and  lasting  for  a  few  weeks 
at  a  time,  during  which  ambulatory  treatment  can  be  given) 
attains  the  goal,  but  his  method  seems  to  have  met  with  little 
approbation. 

In  my  opinion  it  is  not  certain  whether  in  these  cases  a  fresh, 
slight  bovine  infection  may  not  have  occurred  in  the  meantime, 
which  might  often  happen  to  anyone  Avith  the  numerous  oppor- 
tunities for  infection,  from  milk,  and  even  repeated  infection, 
which  would  be  sufficient  to  induce  a  positive  reaction.  There- 
fore I  do  not  consider  a  revival  of  v.  Pirquet's  reaction  an 
indication  for  the  necessity  either  of  treatment  or  a  repetition  of 
treatment  as  Jochmann,  Kraemer  and  others  believe. 


382  SCROrULOSIS 

Ganghofner,  who  coninuinii'au's  ilie  results  of  seven  scrofu- 
lous patients  treated  by  tuberculin,  was  apparently  satisfied  with 
the  success,  but  1  and  one  of  his  reporters  found  the  histor)'  of  the 
patients  1)\'  no  means  so  conx  inciui;,  and  with  respect  to  increase 
in  weight,  \c-.,  c|uile  within  the  bounds  of  what  may  fretiuently 
be  attained   in ,  hos|)iials  without   tuberculin   treatment. 

Escherich,  v.  Pirquel,  Jochmann  and  others  also  recommend, 
especially  as  regards  tuberculosis  and  scrt)fulosis  in  children, 
tubercidin  in  the  smallest  doses  and  gradually  increased.  Aronade 
considers  this  treatment  promising  in  bone  and  joint  tuberculosis, 
but  warns  against  its  use  in  pulmonar\-  lul)erculosis,  in  which  it 
often  furthers  the  calaslropht^  of  a  spread  of  the  bacilli.  Philip 
and  Zumsteeg  saw  imj)royement  in  tuberculosis  of  the  glands, 
liiederi  in  l-)one  and  joint  tuberculosis  and  eczema  of  the  head, 
(as  also  did  Smith,  Pliilii)  and  others),  Laas  in  scrofulosis  of  the 
eves,  Krause  in  tuberculosis  of  the  glands,  using  bacillarv 
emulsion. 

It  is  uncontested  that  phlvciencC,  blepharitis,  eczema  and  the 
facies  scrofulosa  often  pass  off  after  tuberculin  treatment,  as  is 
also  noted  bv  Epstein,  Ganghofner,  Heubner,  and  Escherich  (see 
Diathesis,  p.  31).  But  the  frequent  reappearance  after  a  time 
makes  the  therapeutic  value  seem  problematical.  In  treating 
cases  which  are  not  supported  by  sure  clinical  diagnosis,  but  in 
which  the  diagnosis  is  founded  only  on  the  tuberculin  reaction, 
we  run  the  danger  of  claiming  imaginary  success  when,  de  jacto, 
only  an  inactive  healed  focus,  or  perhaps  a  bovine  infection  healing 
of  itself,  was  the  cause,  processes  which  did  not  need  treatment. 
The  fear  that  the  diagnosis  is  not  reliable  is  also  shared  hv 
Pell  and  others.  Czernv  expresses  his  doubts  in  the  most 
decided  manner  when  he  refers  the  apparentlv  favourable  results 
of  Dautwilz  with  tuberculin  treatment  j^rincipalh'  to  the  fact  that 
Dautwitz  chose  the  slightest  cases  for  his  treatment,  that  is  to 
say,  children  suspected,  but  not  j^roved  to  be  tuberculous.  In 
this,  says  Czerny,  he  follow"S  the  example  of  nearlv  all  heads  of 
sanatoria,  w^hose  principal  desire  it  is  to  distinguish  themselves 
by  successes. 

Therefore,  taken  altogether,  it  is  certainly  not  a  neglect  of 
professional  duty,  as  Goetsch  thought  it  to  be,  if  we  do  not 
employ  tuberculin  even  in  the  earlier  stages,  for  a  sure  proof 
has  not  yet  been  brought  forward  that  success  is  not  just  is 
frequently  attained  without  it.  Although  large  doses  have  led 
in  some  cases  to  surprising  cures  in  my  experience — I  had  in  the 
year  1890  over  400  cases  under  treatment — thev  are  decidedly  to 
be  dreaded;  onlv  the  smallest  doses  are  to  be  used,  which  will 


TIIKRAI'KUTICS  383 

jusi  sliglilly  inil.'iU-  llic  l  ul)ci<  iiloiis  lissiic  ;iii(|  cxciK;  il  In  innain- 
malory  reaction  llic  (  liid  licilinL;  l;i(  im  ;ind  ycA  which  will  nf)l 
induce  inriaiTimaloiy  liansud.-ii  ion.  Sim  h  1  rr'alm(;nl,  which  avoids 
every  manifest  local  and  ^c\)i-y:\\  ii;i(iioii,  naliiraliy  spreads  over 
many  monllis,  (;ven  years,  and  tlm-s  imi  pidcnd  lo  any  asl(»n- 
ishing  success;  even  willi  a  la\  niiial)lf  (oiirst;  ot  IJie  disease  one 
must  always  allow  llic  ohjci  1  ion  dial  die  disease  was  cured  spon- 
taneously or  by  nidi\<;i<'ni(  nicaMiics  lakcn  siniullaneously,  and 
proof  lo  llie  conlrar\'  will  \u-  dinimli  lo  prodiKc  In  manv  cases 
tuberculin  mav  render  xaluable  sei\  i( c  as  a  MK'diiini  lor  assistinj^ 
olher  llierapeulic  remedies. 

MODI<:  OF  USE. 

In  any  case  it  is  only  to  l)e  used  in  die  smallest  doses  of   ,  ' 

-'  -^  I  nil 

to  Y^,\)(y  mg.  to  begin  with,'  and  slowly,  avoiding  reaction  as  far  as 
possible,  watching  closely  the  temperature  and  local  phenomena, 
increasing  the  dose  after  a  pause  of  about  two  or  four  days.  In 
case  of  a  reaction  it  must  be  discontinued  until  the  reaction  has 
entirely  ceased,  and  then  the  same  dose,  or  (jne  slightly  smaller, 
may  be  repeated.  As  the  susceptibility  to  tuberculin  varies  even 
in  the  same  patient  at  different  times,  and  that  A\ithin  very  wide 
limits,  a  fixed  general  rule  is  above  all  things  to  be  avoided. 

If  the  patient  stands  the  reaction  Avell  the  dose  is  increased 
slowly  and  cautiously  to,  at  most,  o'l  gramme,  only  exceptionalh' 
higher.     Salge  and  others  consider  i  mg.  the  maximum  dose. 

Following  the  example  of  Salrli,  who  also  recommends  the 
smallest  doses  and  avoiding  reaction  as  far  as  possible,  Beraneck's 
tuberculin  is  often  used  for  early  cases  in  which  there  is  no  fever; 
this  is  supplied  in  thirteen  different  solutions  75V,  j-^,  s<  ?<  ^, 
A,  B,  C,  D,  E,  F,  G,  H. 

The  length  of  treatment  extends  over  at  least  three  to  six 
months.  If  Beraneck's  solutions  are  then  found  to  suit  the 
patient  the  injections  mav  be  limited  to  one  per  month,  and  are 
continued  for  a  considerable  length  of  time.  The  first  dose  is 
one  division  of  the  ^V  solution  ;  for  children  one  begins  with 
J  division  ^\,  and  for  children  under  6  years  with  one  division 
of  -^  and  --- 

Oi    64    '••"''l    256- 

Personally  I  have  often  used  Beraneck's  serum  without 
evidence  of  any  harm  to  the  patient. 

Wallerstein  has  tried  the  most  harmless  application  of  tuber- 
culin  for  therapeutic  purposes.      He  applied  it    in   the   form  of 

^  Riviere  gives  children  up  to  1  year  jwloo  to  ^^o !    up  to  5  years  of  age 
4t/oo  ■'    older  children  aoVu  mg.  tuberculin. 


384  SCKOFULOSIS 

V.  l^iiqiiL'i's  cutaneous  reaction.  lie  begins  with  one  drop  of 
I  per  cent,  solution,  and  waits  till  reaction  has  entirely  dis- 
appeared; then  he  inoculates  again  with  the  same  solution  till  no 
reaction  takes  place,  then  with  \  to  j  per  leni.  gradually  until  he 
has  increased  to  about  5  per  ccm.  Wallersu-in  mentions  favour- 
able results  in  six  cases,  some  of  whom  sultcrcd  trom  scrofulosis. 
Finkelslein  attained  lirilliant  results  in  two  cases  of  surgical 
tuberculosis. 

Others,  especially  French  doctors,  prefer  Denys's  tuberculin. 
Recently  Marmorek's  serum  has  been  warmly  recommended  by 
manv,  Init  with  some  reservation  :.  Frey,  Glaessner,  Hemsted, 
Hvmans  and  Polak,  Daniels,  Hoffa,  Hohmeier,  Morner,  v. 
Huellen  and  ]\Ionod  (who  gives  collective  references  to  thirty-five 
authors),  Postnikow,  Petit,  Preleitner,  Schenker,  Schndller, 
Sikemeier,  Straus  and  Thorspeken  (who  uses  it  in  early  cases  for 
three  months,  in  other  cases  for  six  to  twelve  months),  Ullmann 
(who  used  it  in  scrofulous  eye  affections),  Wein  and  Wohlberg 
(who  gives  it  per  rectum  in  the  evening  with  a  simple  glycerine 
svringe,  5  c.c,  and  if  it  agree  with  the  patient  10  c.c.  for  twenty- 
one  davs ;  after  an  interval  of  ten  days  the  series  is  repeated). 
Rectal  use  is  now  generallv  preferred.  Others,  on  the  contrary, 
found  Marmorek's  serum  to  be  sometimes  without  effect,  and 
sometimes  directly  harmful  (Bock,  Ganghofner,  Molmboe,  Karo, 
Kaufmann,  Kohler,  Kroner  and  Szurek), 

Spengler's  preparation  of  immune  bodies  (I.K.)  was  highly 
praised  for  a  time,  and  was  also  recommended  in  recent  times  by 
Benohr  and  Hoffmann,  Dresdner  (in  three  cases),  Gernzheim, 
Herzberg,  Selter,  Wallerstein  and  Westphal,  while  others  speak 
very  reservedlv  of  it,  or  inform  us  of  bad  experience  :  Alexander, 
Exner  and  Lenk,  Kerl6,  Roth,  Sarkloff,  Schafer,  Simon,  Szaboky, 
Weicker  and  Bandelier,  Weihrauch  and  Weintraut. 

With  respect  to  v.  Behring's  employment  of  human  bacilli 
for  rendering  children  immune,  N.  Raw,  taking  for  granted 
(which  is  certainly  not  tenable)  that  glandular  and  bone  tuber- 
culosis may  be  referred  to  bovine  bacilli,  and  pulmonary  tuber- 
culosis to  human  bacilli,  recommends  human  tuberculin  for  the 
treatment  of  glands,  and  bovine  serum  for  human  tuberculosis; 
Pottenger  recommends  the  same. 

Cantani's  observation  must  also  be  mentioned,  that  tuber- 
culous patients,  after  intensive  treatment  with  iodine,  react 
negatively  to  tuberculin,  and  with  combined  treatment  of  iodine 
and  tuberculin  soon  accustomed  themselves  to  enormous  doses  of 
tuberculin. 


THERAPEUTICS  3H5 

CINNAMIC  ACID. 

riic  ircalinenl.  with  cinnamic  acid  was  recommended  by 
Landeror  for  pulmonary  tuberculosis  and  in  tlif  luberculous  fcjrm 
of  scrofulosis,  f(jr  (ul)erculous  glands,  bone  and  joini  alb-ctions, 
and  for  luj)us. 

'I'lic  sodium  cinnamaU;  "  licioj,"  from  Kalle's  lactory, 
Biebricli  on  Khine  (to  be  kej)!  in  coloured  glass  bottles,  and 
filtered  and  sterilized  before  usej,  is  injected  in  f|uantiiies  of  i  \(> 
5  per  cent,  in  physiological  salt  soluticm  into  the  vein  of  the 
elbow,  which  has  been  previously  constricted  with  an  india-rubber 
band,  and  disinfected  with  sulphuric  ether  and  sublimate  solution. 
The  s}'ringe  is  to  be  first  disinfected,  and  washed  out  with  a 
physiological  salt  solution;  the  cannula  nuisi  be  placed  in  80  per 
cent,  rectified  spirit.  The  gluteal  injection,  which  is  less  effective, 
was  used  by  Landerer  only  in  the  case  of  very  young  children. 

After  noting  the  temperature  for  two  or  five  days  one  begins 
with  I  mg.  hetol  injected  every  two  or  three  days  in  the  morning, 
increasing  i  mg.  at  every  injection,  in  advanced  cases  increasing 
05  mg.  in  a  week.  When  25  mg.  is  reached  that  dose  is  con- 
tinued for  two  months,  and  after  a  return  to  i  mg.  the  dose  is 
increased  more  rapidly.  After  four  or  six  months  a  two  months 
interval  is  given.  Excessive  doses  cause  a  rise  of  temperature 
and  loss  of  weight.  When  the  leucocytes  amount  to  i  :  .-^oo  an 
interval  is  indicated.  There  is  a  tolerably  ample  literature  on  the 
cinnamic  method,  many  opinions  are  favourable,  others  decide 
against  it ;  at  any  rate,  at  present  it  has  almost  gone  out  of  prac- 
tice, although  the  idea  on  which  it  is  based  appears  rational,  and 
healing  processes  seem  to  have  been  proved  anatomically  in 
animals  (see  Cornet,  "  Die  Tuberculose,"  second  edition,  p.  1030) 

SAPO  VIRIDIS. 

Friction  with  soft  soap,  recommended  by  Kappesser,  takes 
a  peculiar  place  in  the  treatment  of  scrofulosis.  He  noticed  in  a 
delicate  boy,  aged  9,  after  long  continued  rubbing  in  of  soft 
soap  for  scabies  that  scrofulous  symptoms  which  had  before  been 
treated  with  varying  success  (glandular  swellings  in  the  neck, 
inflammation  of  connective  tissue,  &c.)  at  last  disappeared.  As 
he  observed  that  in  other  cases  by  the  methodical  use  of  soft  soap 
involution  took  place  after  several  months  in  extensive  and  deep- 
seated  scrofulous  foci,  ulcers  of  the  skin  and  mucous  membranes, 
he  may  claim  soft  soap  to  be  an  effective  remedv. 

Richter,  in  1846,  had  recommended  washing  with  soft  soap 
every  evening  for  scrofulosis. 

25 


386  SCROFULOSIS 

Haussmann  soon  contirmed  the  favourable  effect  in  a  few 
cases,  especially  in  pure  scrofulosis  (and  in  an  affection  of  the 
lungs  (phthisis),  of  the  pleura  and  perhaps  of  the  mesenteric 
glands);  Klingelhoeffer  used  it  in  advanced  scrofulosis  of  the 
mesenteric  glands.  Senator  convinced  himself  of  the  apparent 
effect  of  sapoviridis  in  furthering  absorption  of  exudates  of  the 
pleura,  pericardium,  peritoneum  and  the  synovial  membrane,  is 
well  as  in  the  remains  of  syphilitic  suppuration  of  the  lymphatic 
glands.  Kollmann  saw  good  results  in  caries  of  the  tarsus,  also 
of  the  sternum,  and  once  in  connection  with  pulmonary  tuber- 
culosis. Kormann  observed  "  disappearance  of  scrofulous  in- 
filtrations with  a  rapidity  hitherto  unknown,  considerable  shorten- 
ing of  the  course  of  scrofulous  eczema,  and  an  improvement  in 
the  infiltrations  at  the  apices  of  the  lungs  "  in  scrofulous  eczema, 
and  infiammation  of  the  eyes  with  infiltration  of  the  glands. 
Iloffa  has  informed  us  of  "wonderful  successes"  in  greatly 
debilitated  children  with  multiple  bone  and  joint  affections. 
Biedert  also  mentions  results  wdiich  were  sometimes  astonishing. 
The  considerable  improvement  in  appetite  and  nutrition  and 
general  health  has  been  emphasized  by  many,  and  decided  benefit 
has  been  stated,  also  in  tuberculosis  of  the  bronchial  glands.  For 
many  years  I  have  had  favourable  experience  with  the  use  of  soft 
soap.  After  all  this  experience  I  can  recommend  the  earliest 
possible  application  of  soft  soap,  at  any  rate  at  the  beginning  of 
scrofulous  symptoms. 

The  special  mode  of  action  has  not  yet  been  made  clear.  In 
general,  sapo  viridis — a  combination  of  several  fatty  acids  with 
potassium — when  rubbed  into  the  skin  causes  a  loosening  of  the 
epidermis  by  means  of  the  free  carbonate  of  potassium  contained 
in  it,  and- — when  there  is  some  lesion  of  the  skin — irritation  of  the 
connective  tissues,  which  are  rich  in  lymphatics  (Husemann) ;  i 
slighter  effect  is  redness  of  the  skin,  and  a  stronger  effect  inflam- 
mation of  the  skin.  Perhaps,  too,  the  massage  plays  a  certain 
part  (see  p.  411).  Senator  supposes  that  the  potassium,  which  is 
the  chief  component  of  the  soap,  acts  on  the  tissues  as  a 
liquefactor. 

Kappesser's  method  is  as  follows  :  The  ordinary  brown  soft 
soap  is  gently  rubbed  into  the  skin  (twice  a  week  before  going  to 
bed,  about  half  to  one  and  a  half  tablespoonfuls  diluted  with  warm 
water)  either  with  the  hand  or  a  soft  woollen  rag  over  the  whole 
of  the  back,  from  the  neck  to  the  popliteal  spaces,  if  the  back 
should  be  erythematous  the  front  is  rubbed ;  the  surface  is  then 
washed  with  warm  water  or  bathed,  the  child  is  then  dried  and 
laid  in  bed.     The  localization  of  the  disease  is  of  no  consequence 


-iiii:i<Ai'K(jTjcs  3^7 

in  deciding  the  silc  of  the  rubbing,  but  it  may  lai<c  place  any- 
where; fur  example,  llie  breast  in  bronchial  gland  scrofuUjsis,  liie 
abdomen  in  scrofulosis  of  the  mesenteric  glands.  K  oil  man  n  recom- 
mends sapo  kalinus  venalis  with  excess  of  potash  ;  Iloffa  gives  the 
preference  to  tliis,  too ;  with  fussy  patients,  Senator  adds  ethereal 
oil  and  oil  of  lavender  on  account  of  the  disagreeable  odour.  Some 
rub  in  every  other  day,  some  daily,  some  even  twice  daily.  (-)thers 
let  the  soiip  remain  on  the  skin  for  from  a  quarter  to  hall  an  hour; 
Kormann  only  allows  it  to  l)e  washed  off  next  morning,  and  lets 
the  patient  wear  two  night-shirts  to  avoid  soiling  the  bedclothes ; 
the  skin  scales  in  three  or  four  days,  and  becomes  erythematous. 
He  says  he  has  not  observed  eczema.  Some  attribute  good  results 
from  the  simple  addition  of  the  soap  to  ba(h  water.  With  adults 
more  energetic  measures  may  be  taken  on  account  of  the  harder 
skin. 

Kappesser  deserves  great  credit  for  giving  us  this  method, 
as  the  treatment  is  easily  employed  anywhere,  and  so  may  be 
used  even  for  the  poorest. 

When  we  use  bacon  fat,  which  has  also  been  recommended, 
the  whole  of  the  body,  with  the  exception  of  the  head,  is  well 
rubbed  and  massaged  with  a  cylindrical  piece  of  bacon  fat,  2  to 
5  cm.  thick  and  10  cm.  long,  in  the  direction  of  the  course  of  the 
large  intestine.  Kanzler  praises  this  method  in  scrofulosis  of 
the  mesenteric  glands.  Its  action  is  also  put  down  to  irritation 
caused  by  the  particles  of  salt  rubbed  into  the  skin. 


CHAPTER    111. 

LOCAL   TREATMENT. 


General  ireaimenl  remains  ihe  basis  of  the  therapeulics  of 
scrofulosis,  but  our  comprehension  of  the  etiology  of  the  disease 
leaves  an  important  place  for  local  applications.  Far  more 
importance  is  attached  to  the  treatment  of  the  separate  foci  of 
disease  than  formerly,  when  one  only  expected  relief  of  symptoms 
and  not  effect  on  the  causation  of  the  disease.  If  the  suppuration 
of  the  glands  is  not  the  result  of  a  general  dyscrasia,  but  the 
consequence  of  the  immigration  of  bacilli,  if  the  local  changes  in 
skin  and  mucous  membrane  are  not  put  down  to  a  disordered 
condition  of  the  body  fluids,  but  to  external  toxins,  local  treat- 
ment promises  a  success  which  will  affect  the  actual  course  of  the 
scrofulosis,  especially  the  pyogenic  form.  We  see  daily  how, 
with  healing  at  the  periphery  and  a  cessation  of  the  process  of 
disease  and  of  the  further  entrance  of  noxious  germs,  the  irritated 
and  swollen  glands  recover  of  themselves  !  In  the  tuberculous 
form  local  treatment  at  the  point  of  entrance  may  at  least  prevent 
mixed  infection,  which  under  some  circumstances  is  so  dangerous. 

A.— SKIN   DISEASES. 

ECZEMA. 

Powdering  with  rice  or  wheat  starch,  with  the  addition  of 
I  per  cent,  red  kaolin  for  colouring,  or  with  amvl.  oryz^e  90  per 
cent.,  pulv.  irid.  florent  10  per  cent.,  has  proved  of  value  in 
weeping  acute  eczema.  Lassar's  paste,  with  or  without  salicylic 
acid,   is  also  useful. 

B    Acidi    salicyl.  ...  ...  ...         ...         ...       2'o 

Zinci  oxyd. 

Amyl.    puri.  aa    24*0 

Vaselini  flavi 

Seu  lanolini.  ...  ...  ...  ...  ...     5o'o 

M.  leniter  terendo  exactissime,  f.  pasta. 

This  drying  paste,  which  is  protective  as  well,  is  laid  on  the 
skin    with  a   brush   after   any   scab   has   been    removed   and   the 


'mi;KAi'i;i  I  ics  389 

puslules  of  impetigo  carcfuH)  »'nipli<-(l  wiilioiii  injuring  liie  cutis. 
After  the  surface  has  been  powered  c^ver  it  forms  a  wliite  hard 
crusl,  under  vvliich  the  eczema  heals.  C)r  we  may  u.se  zinc  oxyd., 
amyl.  (ril.  ila  5*0,  or  nosophen,  laic,  venet.  aa  5'o.  Impetigo 
may  be  treated,  according  to  I^sciierich,  wilh  great  effect  f)y  com- 
presses of  3  per  cent,  perhydrol. 

Multiple  skin  abscesses,  after  (  Icansing  ihe  surface  with 
methylated  spirit  soap,  should  !)<■  opened  and  emptied,  and 
covered  with  cotton-wool  moistened  with  02  per  1,000  sublimate 
solution,  then  with  dry  cotton-wool,  and  sealed  with  collodion  in 
extensive  eczema.  Biedert  recommends  a  decoction  of  oak  bark 
125  to  4,000  boiled  down  to  2,000;  lOO  to  200  put  aside  as  a  bath 
for  a  child,  or  an  addition  of  a  decoction  of  wheat  bran  (Pick),  or 
bathing  with  permanganate  of  potash  and  afterwards  powdered. 

If  there  be  great  irritation  and  no  excoriation,  a  spirituous 
solution  of  thymol  J  to  J  per  cent.,  carbolic  acid  ^  to  3  per  cent., 
or  menthol  i  to  3  per  cent,  is  indicated,  or  else  an  ointment  of 
tumenol  or  menthol. 

With  a  dry  skin  Unna's  zinc  gelatine  renders  excellent 
service,  for  example  :  — 

B     Zinci.    oxyd. 

Gelatini  ...  ...  ...  ...  ...         aa    lo'o 

Glycerini  , 

Aq.    destill.  ...  ...  ...  ...         aa    40'o 

Rendered  fluid  in  a  hot-water  bath,  it  is  painted  on  thinly 
with  a  brush,  and  forms  a  flexible  protective  covering. 

Dry  eczema  needs  a  more  simple  softening  remedy,  and  is 
smeared  over  with  ung.  diachvlon  hebrjE,  or  10  per  cent,  boric 
ointment,  or  ung.  Wilsonii  (benz.  pulver.  5*0,  adip.  suill.  i6o'o, 
dig.  cole  et  adde  zinci  oxyd.  25"o),  arid  if  these  ointments  still 
irritate,  with  cod-liver  oil,  and  covered  with  a  bandage. 

Unna's  ointment  mulls  are  very  convenient,  fixed  with 
suitable  bandages;  e.g.,  zinc  oxide  ointment  mull,  but  especially 
the  gutta-percha  plaster  mull,  and  the  paraplast  of  Unna- 
Beiersdorf,  such  as  zinc  oxide  or  salicvlic  acid  paraplast,  which 
need  no  further  fixing. 

Biedert  recommends  compresses  with  3*5  per  cent,  boric  acid 
fixed  with  gutta-percha  and  bandages,  and  changed  morning  and 
evening. 

With  obstinate,  torpid,  scaly  eczema  preparations  of  tar  are 
used,  such  as  juniper  tar. 

B     01.   cadmi  puri   (or  ol.   rusci,   or  ol.   fagi)       2-10 

Vasel.  flav.  3.  ol.  oliv.  2o'o,  then  ol.  cadini  pur. 

D.S.     Applied  twice  a  day  with  a  brush,  then  powdered,   and  covered 
with  a  simple  ointment  mull.  ' 


390  SCROFL  LOSIS 

As  a  precaution,  ii  is  better  to  put  lirst  a  weak  preparation 
on  a  small  place,  as  now  and  then  severe  irritation  is  caused,  or 
Unna's  casein  ointment  is  used,  with  an  addition  of  20  per  cent, 
tar  or  less;  with  callous  thickenings  the  tar  is  replaced  by  an 
addition  of  the  same  quantity  of  soft  soap ;  besides  this,  the 
following  is  recommended  in  the  squamous  eczema  of  children  :  — 

B  Hydragyri  prgec.    albi    ...         ...      To    U  Bismuth    subnitr.      ...         ...  io"o 

Balsami.   pcruv.              ...         ...     s'o          Zinci    oxyd ...  2'o 

Ung.  Wilsonii  ad.  30'o  (Saalfeld)              Glycerini 8'o 

Vasclini    flavi.           ...          ...  3o'o 

In  eczema  which  heals  with  difficulty,  de  Lange  recommends 
painting  with  5  per  cent,  watery  solution  of  tannin. 

In  eczema  of  the  hairy  scalp  preparations  of  tar  agree  in  the 
early  stage.  The  crusts  and  scabs  are  to  be  previously  softened 
by  repeated  compresses  of  olive  oil,  or  a  combination  of  thymol 
(2)  with  olive  oil  (100),  or  the  cheaper  linseed  oil,  or  with  boric 
ointment,  but  especially  sometimes  with  cod-liver  oil,  and  removed 
with  a  comb  laid  flat.  A  hot  washing  daily,  or  every  two  or  three 
days  with  fluid  tar  soap,  or  soft  soap,  or  ichthyol  soap,  or  sapo 
kalinus,  and  then  covered  with  unguent  diachyl.  80,  ol.  jec.  as. 
20,  are  sometimes  useful.  When  tar  is  too  irritating,  Biett- 
Lassar's  cinnabar  ointment  is  used. 

B  Hydrarg.  sulph.  rub.  ...  ...  ...  ...  I'o 

Sulph.  sublim.         ...  ...  ...  ...  ...  24*0 

Olei    bergamotti      ...  ...  ...  ...  gtt.  xxv 

Vaselini  flavi            ...  ...  ...  ...  ...  75*0 

M.f.ung.     S.  to  be  applied  twice  a  day  with  a  firm  brush. 

Plaster  is  less  used  on  account  of  sticking  to  the  hair. 

In  eczema  of  the  face,  Lassar's  paste  and  ointment  mulls  are 
suitable,  openings  being  cut  for  the  nose,  mouth  and  eyes ;  when 
necessary  they  can  be  varied  by  occasional  powdering. 

In  eczema  of  the  nostrils  loose  vibrissas  are  removed,  pustules 
if  present  opened,  scabs  softened  with  olive  oil,  rhagades 
cauterized  with  5  to  10  per  cent,  solution  of  silver  nitrate  or  the 
silver  nitrate  point,  and  then  Hebra's  ointment,  or  ung.  hydrarg. 
prsecip.  alb.,  applied.  Besides  this  we  may  introduce  plugs  of 
cotton-wool,  with  sublimate  solution  (i  to  1,000  two  or  three  times 
a  day  for  two  hours — Schmiegelow),  or  menthol  oil  (10  to  100),  or 

B     Acidum  tannicum  ...         ...         ...         ...       ro 

lodoli  ...         ...         ...         ...         ...         ...       2*0 

Lanolini         ...  ...  ...  ...  ...  ...      lo'o 

is  to  be  recommended,  and  the  accompanying  nasal  catarrh  must 
also  be  treated.  In  dry,  scaly  eczema  the  tannin  vaseline  oint- 
ment (5  to  10  per  cent.)  has  proved  of  service. 


tiii:k.\I'|j;tic.s  39  ^ 

For  eczema  of  I  he  auricle  I  In-  j)u\v(lfring  above  described  is 
used  (to  avoid  bloclcing  the  m(;alus  a  i)lug  of  coLlon-\v(jol  must  be 
first  introduced),  vviiich  can  also  be  placed  in  ihe  r-c/.ematous  ear 
passage  laid  on  col  ton-wool. 

The  vi(jlent  pain  of  acute  (Mzema  may  b(;  relieved  by  applying 
linen  rags  soaked  in  ice-cold  olive  oil  (Jacobson).  In  scaly  eczema 
of  the  external  nicalus  Schwarl/c  recommends  jKiiniing  with  3  to 
10  per  cent,  nitrate  of  silver  sdulion,  ai)|ilying  later  white  pre- 
cipitate ointment.  Naturally,  if  the  Icjbes  of  the  ear  are  affected 
no  earrings  may  be  worn. 

For  nose  and  ears  the  ointment  mull  is  very  convenient. 

Eczema  of  the  eyelids  is  treated  with  Lassar's  pa.ste  or 
hydrarg.  prcccip.  alb.  (1  to  10  vaselini  flavi)  or  tar  ointment; 
accompanying  conjunctivitis  may  be  treated  with  sublimate  solu- 
tion (o'oi-o"05  to  100)  (Trousseau). 

Arsenical  preparations  (see  p.  375)  internally  appear  to  have 
a  favourable  effect,  and  phosphorized  cod-liver  oil  as  a  disinfectant 
of  the  intestines  (Pick).  Zinc  powder  treatment  is  generally 
sufificient  in  intertrigo.  Thioform  is  especially  recommended  by 
Fiirst  after  dabbing  with  cotton-wool  and  a  3  per  cent,  solution 
of  acetate  of  aluminium ;  also  the  chrysarobin  ointment  recom- 
mended by  Pick  (litharg.  io"o,  ol.  oliv.  40*0,  chrysarobin  0'5) 
twice  daily  smeared  on  linen  and  applied  does  good;  otherwise 
cauterizing  with  a  3  per  cent,  solution  of  silver  nitrate  is  indicated. 

Water  applied  to  the  skin  by  baths  and  washing  does  not 
generally  agree  with  eczema. 

A  very  detailed  and  excellent  treatise  on  the  treatment  of 
scrofulous  eczema  is  to  be  found  in  Pentzoldt-Stintzing's  Hand- 
buch,  vol.  ii,  bv  Eversbusch,  and  in  the  German  Klinik,  vol.  x,  2, 
by  Klingmiiller. 

Of  other  remedies  the  following  have  proved  useful  : 
Sozoiodol  in  scrofulous  affections  of  the  scalp  and  scrofulous 
ulcerations  (Hofmann),  zeroform  as  a  remedy  forming  a  film  over 
the  surface  is  also  useful  in  eczema  of  the  nostrils  (Berend  and 
Fasano),  vasogen  as  a  vehicle  is  especially  recommended  bv 
Friedlander  in  scrofulous  eczema.  Thioform  renders  good  service 
in  eczema  of  the  face  with  scrofulous  inflammation  of  the  eves, 
and  naphthalan  (Waldmann  and  Goldzieher). 

Unna  found  good  efTects  from  ceramin  soap  (Topfer)  in  scalv 
eczema  of  children,  and  still  more  in  intertrigo  and  vesico-papular 
eczema  and  lichen  urticatus. 

In  lichen  urticatus  Ruediger  attained  good  results  with 
irradiation  daily  for  ten  or  fifteen  minutes,  focused  behind  the 
patient.     Cedercrentz,  on  the  other  hand,  recommends  abstaining 


39-  ■  SCROFLLOSIS 

from  eggs,  and  preparations  of  \east  and  calcium  lactate,  so  much 
used  in  England;  Saalfeld  has  seen  slrt)fulus  disappear  after  the 
use  oi  naphthalan. 

Finkelstein's  diet  for  eczema  :  Based  on  the  acceptance  of 
the  theory  that  the  whey  salts  in  cows'  milk  influence  eczema 
deleteriously,  Finkelstein  recommends  a  diet  containing  little 
salt. 

Finkelstein's  eczema  food  :  One  litre  of  new  milk  is  curdled 
with  one  tablespoonful  of  essence  of  rennet  and  kept  in  a  water- 
bath  at  42°  C  for  half  an  hour  and  strained  through  linen  ;  the 
cheese  curd  is  made  into  a  firm  ball,  rubbed  through  a  hair  sieve 
with  half  a  litre  of  water,  then  half  a  litre  of  buttermilk  is  added. 

Opinions  differ  as  to  the  efficacy  of  food  poor  in  salt.  In 
eczema,  Meubner,  Langstein,  Mendelsson  and  Geisler  mention 
very  good  results,  especially  after  continued  use.  Witzinger,  in 
eight  cases  of  over-nourished,  flabby  children,  some  with  moist 
eczema,  some  with  scaly  eczema,  had  only  one  case  decidedly 
successful.  But  the  loss  of  weight  was  considerable,  the  general 
health  deteriorated,  in  some  cases  the  food  did  not  agree  with 
the  patient  for  long.  Kramsztyk  observed  improvement  in  four 
out  of  six  cases,  but  relapse  occurred,  and  in  one  oljstinate  case 
the  condition  only  improved  on  a  diet  poor  in  fat  (buttermilk) 
and  by  using  tumenol  ointment.  Spiethoff  and  others  met  witli 
no  success. 

Diet  poor  in  whey  and  salts  appears,  therefore,  to  have  had 
a  favourable  action  in  some  cases,  but  shares  this  effect  with  every 
form  of  nourisliment  which  reduces  the  weight  of  the  body,  for 
o\er-nourishment,  if  not  the  onlv  causative  agent  of  eczema  in 
infants,  is  probabl}'  at  least  one  of  them  (see  also  j\Ioro  and  Kolb). 
Feer  attained  the  same  results  with  the  scantv  diet,  poor  in  milk, 
introduced  by  him,  A\ith  the  addition  of  meal,  excluding  eggs  and 
meat,  and  at  a  later  age  giving  vegetable  food.  Eczema  of  the 
hairy  scalp  and  face  he  considers  to  be  especiallv  suited  for 
dietetic  treatment,  but  eczema  over  tlie  whole  body  with  severe 
itching  is  less  susceptible  to  it. 

In  any  case,  Finkelstein's  diet  may  onh'  be  tried  with  C£iution 
in  fat,  flabbv  children  wlio  can  stand  reduction  in  weight,  and  the 
fall  in  weight  must  be  kept  within  moderate  bounds. 

Marfan  emphasizes  the  beneficial  influence  of  a  stay  of  four 
or  six  weeks  in  a  mountain  climate  (1,000  to  1,500  metres  above 
the  sea)  in  eczema  of  infants.  After  a  week  the  eruption  becomes 
paler;  after  a  fortnight  only  a  few  dry,  scaly  places  remain  ;  now 
and  then  it  recurs  at  lower  levels,  but  often  the  cure  is  lasting. 


-I'lll-.KAI'IJ.TICS  393 

Lupns. 

Many  surgical  and  clicmic.il  iikI  hods  have  b(;<tn  acJojilcd  for 
lupus,  several  of  which  lead  lo  lolcrahly  satisfaclory  results,  both 
as  regards  cure  and  a  good  s(  ai',  |)rovidfd  iIk-  docior  possess 
the  necisssary  skill,  and  hoih  docior  and  pamiii  ili'-  ii'-ressary 
patience  and  perseverance. 

Kxcision  takes  the  lirsi  place  II  made  m  really  healthy 
tissue  (localized  bv  luberculiii  injections)  and  liel|)ed  by  skin 
grafting  recurrence  will  fre(|uently  not  take  place,  according  lo 
the  numerous  experiences  of  Thiersch,  Sanger,  Ilelferich, 
Schwarze,  Jarisch,  O.  Witzel,  Sapeschko,  Lang-Popper,  Buschke, 
Schultze,  and  others.  But  unfortunately  cosmetic  considerations 
concerning  extent  and  seat  of  the  disease  limit  the  employment 
of  this  method. 

At  the  Lupus  Conference,  held  in  Berlin  in  1910,  Lang 
spoke  very  decidedly  on  the  surgical  treatment  of  lupus,  support- 
ing his  views  by  the  fact  that  of  308  cases  treated  by  excision  and 
skin  grafting,  276  showed  a  lasting  cure,  amongst  which  were 
cases  of  lupus  of  the  face  larger  than  a  five-shilling  piece  (see  also 
Jungmann  and  others). 

According  to  Volkmann,  one  may  succeed  in  eradicating  the 
lupus  tissue  tolerably  completel_y  with  the  sharp  spoon  ;  also  with 
with  the  thermo-cauterv  or  galvano-cautery.  When  of  limited 
extent  all  diseased  tissue  may  be  removed  at  once ;  but  with  larger 
foci  the  probability  is  increased  that  several  foci  of  bacilli,  which 
have  advanced  singly  into  the  healthv  tissue,  escape  the  visual 
means  at  our  command,  and  only  betray  their  existence  months 
after  by  recurrence  of  the  disease.  In  this  case  tuberculin  renders 
valuable  assistance  by  confirming  lupus  tissue,  and  later  acting 
as  a  control.  One  disadvantage  of  the  sharp  spoon  is  the 
possibility  of  introducing  bacilli  into  the  healthy  tissue. 

The  punctiform  method  of  multiple  scarification  recom- 
mended by  E.  Vidal  and  Balmanns-Squire  (by  which  hundreds 
of  pricks  are  made  close  to  each  other)  is  suitable  for  non- 
ulcerating  lupus;  with  purple  margins  which  raise  suspicion  of 
recurrence,  it  leaves  sightlv  scars  and  appears  to  have  had  good 
results,  but  is  painful  and  tedious.  According  to  Renouard,  for 
instance,  a  lupus  was  scarified  by  \"idal  for  twenty-two  months  in 
188  sittings  (Leloir).  Besides  which,  a  certain  danger  cannot  be 
denied  in  that  bv  pricking,  scarification  and  scraping  the  bacilli 
mav  be  further  disseminated,  although  proof  mav  be  wanting  of 
the  causative  connection  between  later  recurrence  and  scarification. 
Scarification  also  serves  to  improve  the  appearance  of  old  scars 


394 


SCROFLLOSIS 


which  have  been  caused  by  other  means  (Leloir).  Jacobi  has 
used  fine  galvano-caustic  punctures,  whicli  have  often  proved  ot 
service  in  hipus  of  the  mucous  membranes. 

According  to  Gartner  and  Lustgarten,  electrolysis  can  only 
be  entertained  for  small  infilirations,  especiahy  in  the  face. 

Chemical  remedies  used  to  destroy  fresh  formations  in  lupus 
are:  Vienna'  paste,  Cosme's  arsenic  paste  (acid,  arsen.  ro, 
hvdrarg.  sulf.  rubr.  0-3,  ung.  lenient,  ad  30-0),  formerly  much 
used,  and  though  painful,  still  recommended  by  Neisser  and 
others,  chloride  of  zinc  points,  chromic  acid,  carbolic  acid,  lactic 
acid  (Mosetig-Moorhof),  chrysophanic  acid,  and  pyrogallic  acid 
(5  to  20  per  cent,  ointment  with  orthoform),  nitrate  of  silver  point 
(Hebra  and  Kaposi),  caustic  potash  point,  which  penetrates 
deeply,  resorcin,  ichthyol,  salicyl  creosote  (changed  every  four 
hours  and  covered  with  impermeable  zinc  oxide  plaster)  (Unna), 
I  per  cent,  creosolanin  solution,  and  so  on.  Doutrelepont 
observed  good  results  from  sublimate  compresses  frequently 
removed  (i  in  10,000  or  1,000).  In  these  methods  the  healthy 
parts  must  be  carefully  protected  by  zinc  oxide  plaster  mull. 

Of  other  methods  recommended  in  the  treatment  of  lupus  I 
may  mention  ferrichthyol,  thiol,  iodol  (G.  jMazzoni),  isoform,  20 
per  cent.,  iodoformin  and  iodoformal,  euguform  (guaiacol  with 
formaldehyde),  guaiacol  vasogen  (for  intra-nasal  lupus),  alumnol, 
naphthalan,  and  aristol  soap  (in  ulcerating  lupus),  Buzzi's  creosote 
soap,  balsam  of  Peru,  ergot  extract  soap  in  lupus  scars,  fibrolysin 
for  the  treatment  of  scars  and  for  removing  ectropion  after  lupus. 
Dreuw  used  crude  hvdrochloric  acid  (with  chlor.  ethyl  or  under 
chloroform).  Bev  recommends  hvdrochloride  of  quinine  (an 
injection  of  10  gramrnes  2  per  cent,  solution). 

The  effect  of  these  remedies  depends  very  much  on  methods 
of  use  suited  to  different  individuals,  the  dose  and  so  on,  as  well 
as  on  experience. 

Veiel's  method  consists  in  applying  pyrogallol  ointment  (10 
per  cent.)  for  several  days  to  destroy  the  lupus  tissue,  and  a  2  per 
cent,  preparation  to  heal. 

If  I  except  the  more  recent  methods  (see  below)  besides 
excision  (under  narcosis  or  infiltration  anaesthesia),  Ihe  most 
advantageous  method  has  proved  to  be  a  combined  process  of 
scraping  and  pyrogallic  acid  recommended  by  Jarisch,  Lesser, 
Neisser  and  Blaschko,  similar  to  that  mentioned  by  Leloir, 
Neisser,  and  others. 

The  foci  which  are  visible,  and  suspected  places  w'hich  mav 
be  rendered  clearer  bv  preceding  tuberculin  injection,  or  by  the 
pressure  of  a  lens,  are  scraped  out  with  a  coarse  or  fine  spoon  and 


Tlll'.KAl'l'.IJTICS  395 

cauterized  with  i'a(|uelin'.s  cautery,  a  fine  ^^alvanic  cautery  being 
used  for  isolattnl  nodules;  a  number  of  pricks  mny  be  marie  with 
a  g-alvano-caulcrv  in  the  periphery  ot  the  lupus  nodules  tf;  limit 
the  scar,  then  icxloform  (aristol)  is  dusted  on,  or  orthoform  to 
deaden  the  pain,  and  a  bandage  with  acetate  of  aluminium  is  laid 
over;  in  some  cas(;s  on  the  following  day  a  corrosive  substance, 
especially  pyrogallic  ointment  or  lactic  acid,  is  used  twice  a  day 
for  about  live  days  till  the  parts  become  of  a  nut-brown  colour. 

By  proceeding  carefully  we  succeed  in  ,-irresting  the  lupus  for 
a  long  time,  sometimes  in  healing  it  completftly.  'J'o  do  this,  of 
course,  the  patient  must  be  kept  under  closf;  control  for  a  lengthy 
period,  and  if  fresh  nodules  are  found  to  spring  up  (as  seen  under 
pressure  of  a  lens)  we  must  proceed  energetically  and  use  the  fine 
galvano-cautery.  (Jnna  rejects  the  use  of  the  sharp  spoon  (see 
above)  and  Paquelin's  cautery,  and  has  recently  given  the 
following  methods  :  — 

For  eight  to  fourteen  days  the  lupus  is  cauterized  on  (he 
surface  with  the  green  lupus  ointment  (acid,  salicyl.,  licp  antimon. 
chlor.,  aa  2;o,  creosote,  extr.  cannab.  ind.  aa  4*0,  adip.  lana;,  8'o) 
or  potash  paste  (potas.  caust.,  calcar.  ust.,  sapon.  virid.,  aq. 
destill.  aa).  The  cauterized  surface  is  covered  with  the  moist 
paste  and  zinc  oxide  plaster  mull.  Green  lupus  ointment  is  more 
suitable  for  dispersed  lupus  nodules,  the  corrosive  paste  for  the 
sclerotic  form,  or  for  softening  the  intermediate  tissue,  as  well 
as  for  the  points  of  entry  in  the  mucous  membranes,  and  on  them 
(the  tongue  for  example).  It  is  used  daily  or  every  two  or  three 
days. 

After  this,  for  four  weeks  caustic  potash  bandages  are  used 
(compresses  of  caustic  potash  i  or  2  to  5,000) ;  then  follows  for 
two  or  eight  da^^s  a  stippling  process,  small  pieces  of  wood  (such 
as  a  toothpick),  finely  pointed,  which  have  been  soaked  for  a 
quarter  of  an  hour,  or  for  several  hours,  in  liq.  antimonii  chlor., 
are  stippled  with  a  turning  movement  into  the  deep  foci  which 
remain  (the  starting-points  of  recurrence),  and  which  mav  be 
recognized  by  the  diascope  as  dark  brown  spots ;  the  points  are 
cut  ofif  and  the  surface  of  the  wound  covered  with  mercury  carbolic 
plaster  mull.  After  forty-eight  hours  thev  are  removed  from  the 
skin ;  for  three  or  four  weeks  the  potash  treatment  follows,  then 
the  stippling  is  repeated. 

F.  Prondfort  mentions  havino-  seen  ffood  results  from  eivinpf 
thyroid  gland  extract  internally  after  scraping  out  the  lupus  (two 
cases !) ;  Barbe  praises  painting  with  chlorphenol  (monochlor- 
phenol in  a  20  per  cent,  alcoholic  solution).  The  healing  effect 
of  erysipelas  on  lupus  by  inoculation  of  mild  erysipelas  mentioned 


3g6  scROFLLusis 

by  Ilallopeau,  is  styled  by  Besnier  as  transitory,  and  the  thera- 
peutic employment  of  it,  quite  rightly,  as  dangerous,  for  one 
cannot  always  be  sure  of  being  able  to  limii  and  cure  such 
ervsipelas  when  it  has  been  intentionally  induced. 

I  have  sometimes  had  extraordinarily  good  results  by  treat- 
ment widi  old  tuberculin,  but  there  w^ere  also  recurrences.  Latterly 
Doulrelepont  has  spoken  favourably  concerning  the  use  of  tuber- 
culin, and  successes  here  and  there  (Wichmann,  I.itzner,  Jean- 
selme  and  Chevalier)  in  ervthema  induralum  have  been  communi- 
cated, but  just  as  often  failures  (Cxottschalk  and  others  ;  see  p.  382). 
Tuberculin  is  often  employed  by  many  as  an  auxiliary  remedy  in 
local  treatment;  van  Hoorn  says  he  has  had  better  results  with 
the  T.R.  preparations. 

Tuberculin  has  also  been  emploved  external!}'.  Unna  used 
a  tuberculin  soap,  and  \^erge  recommends  friction  with  5  per  cent, 
tuberculin  ointment  for  one  or  two  niinutes,  after  which  the  part 
is  covered  with  ointment  on  linen  for  twenty-four  hours.  lie  had, 
according  to  his  own  account,  good  results  from  this  painful 
method. 

Calomel  injections  are  said  bv  Bernstein  and  Tschlenow  to 
ha\e  a  favourable  influence  on  lupus. 

Hollander  mentions  a  combined  internal  and  external  treat- 
ment for  lupus  of  mucous  membranes.  One  tablespoonful  of 
3  per  cent,  potassium  iodide  solution  is  gi\en,  and  a  quarter  of 
an  hour  afterwards  calomel  is  powdered  on  the  spot,  or  a 
piece  of  cotton-wool  impregnated  with  calomel  is  placed  on  it. 
Hollander  informs  us  of  excellent  success  (see  Alexander). 

Pfannenstiel  tries  to  produce  bactericidal  bodies  in  the 
diseased  tissue  itself,  and  thus  to  start  the  cure;  he  attempts  this 
by  internal  use  of  iodine  and  conducting  ozone  over  the  diseased 
nasal  mucous  membrane.  The  patient  receives  daily  3  grammes 
iodide  of  sodium  in  solution,  divided  into  six  tablespoonfuls, 
besides  which  a  plug  of  gauze,  free  from  starch,  with  HoOo  is 
introduced,  and  he  is  instructed  to  drop  in  hydrogen  peroxide 
(oxydol  Petri  3  per  cent.)  several  times  an  hour  with  a  pipette. 
Strandberg  and  Schaumann  mention  good  results  with  this 
method. 

As  to  more  recent  methods,  for  success,  and  especially  for 
cosmetic  results,  light  treatment  with  ultra-violet  rays  by  Finsen's 
method  is  of  chief  importance.  It  is  distinguished  by  the  forma- 
tion of  a  beautiful  soft,  almost  invisible,  scar;  it  is  very  tedious 
and  costly,  and  can  only  be  carried  out  in  institutions  especially 
arranged  for  it,  and  by  well-trained  attendants,  conditions  which 
exclude  its  use  in  manv  cases. 


TIIKKAI'KIJ'IJCS  397 

The  use  of  K  loin.'i  ycr's  (|ii,-iil/  L-niip  is  siii)pl<-r  in  ils  use  and 
cheaper,  and  is  at  llie  same  lime  lollowcl  by  ^^ood  results  in  ihe 
verrucose  and  scalv  form  of  lupus.  It  should  be  preerrcJed  by 
Finsen's  ilhiminalioii  (/insscr,  (ioiisc  lialk  and  Ifeymannj. 

Hollander's  method  of  hol-air  Ircalmcnl  has  proved  of  ^nv-ai 
use  wilh  (he  special  apparatus  of  Hollander  and  Werther,  and 
forms  smooHi,  j^nxxl  scars.  it  is  cspccialh  suitable  for  treatment 
of  lupus  of  the  mucous  membranes,  espc(  iaily  the  nosf,  but  also 
for  lupus  of  the  face  and  the  extremities. 

The  l\()nt^('n  trealmenl  is  a  de(  ided  advance,  and  is  especially 
suitable  in  hvpertroi)hic,  highly  infill  rated,  intensely  proliferating,' 
forms  of  lupus  with  much  ulceialion,  l)iii  presupposes  great  prac- 
tice and  experience  with  resix-cl  to  the  dose  to  avoid  doinj,^  more 
harm  than  good. 

Whilst  Schiff  and  Freund  endeaxour  lo  av(jid  visible  reactions 
by  using  hard  tubes  and  short  sittings,  separated  by  an  interval 
of  several  days,  Kienbock,  Kiimmel,  Hahn  and  others  endeavour 
to  create  a  slight,  just  visible,  hyperc'cmic  inflammatory  reaction, 
with  strong,  medium  soft  tubes. 

For  severe  cases,  in  which  the  epidermis  and  mucous  mem- 
brane of  the  face  are  affected,  although  it  has  the  advantage  jf 
forming  tolerably  good  scars,  Neisser  considers  this  method  too 
little  assured  against  recurrence  and  goes  on  so  far  with  the  radia- 
tion that  superficial  necrosis  appears,  with  which  he  has  demon- 
strated lasting  cure,  even  after  observation  continued  for  vears. 
One  disadvantage  of  this  stronger  method  is  that  torpid  easily 
bleeding  ulcerations  form,  which,  before  they  heal,  often  require 
treatment  lasting  for  weeks  and  months,  Avith  compresses  of  boric 
acid  and  3  per  cent,  acetate  of  aluminium,  alternatelv  with  balsam 
of  Peru,  or  protargol  ointment.  This  limiting  of  the  capability 
of  regeneration  seems  to  justify  the  warning  of  Gottschalk,  Wich- 
mann  and  others,  with  respect  to  large  doses,  to  go  onlv  as  far 
as  erythema,  and  never  to  allow  dermatitis  and  ulceration  to  occur 
(Lesser).  The  Rontgen  method  has  also  proved  successful  in 
lupus  erythematosus. 

Radium  treatment  has  been  verv  useful,  especiallv  for  single 
nodules  (Zinsser  and  others).  Wichmann  defends  the  emplov- 
ment  of  preparations  of  the  highest  activitv,  at  least  500,000  units 
of  uranium,  by  which  he  obtained  good  results  in  small  lupus  foci, 
and  in  lupus  of  the  mucous  membranes,  with  trained  attendants 
and  by  the  use  of  proper  tiltration  of  the  rays  which  induce 
necrosis  (Bravs). 

This  is  not  the  place  to  go  further  into  these  methods.  The 
following  may  just  be  mentioned  :    Treatment  of  lupus  with  the 


3g8  scROFULOSis 

constant  current  (Philippson) ;  fulguraiion  with  static  electricity, 
which,  according  to  Jacobi,  has  not  proved  of  use;  also  subcu- 
taneous treatment,  with  which  Payr  mentions  success. 

The  more  recent  methods  have  the  great  advantage  that  they 
exercise  a  more  or  less  selective  effect,  destroying  the  diseased 
tissue  and  sparing  the  healthy;  a  further  advantage  is  a  better 
scar  formation  than  can  be  obtained  with  chemical  corrosive 
remedies.  Finsen's  method  fulfils  this  best.  It  is  therefore 
especially  suitable  for  lupus  of  the  face,  where  ugly  scars  spoil 
the  existence  and  life  happiness  of  the  individual,  also  in 
recent  disease  which  has  not  ulcerated.  With  larger  deeply 
penetrating  foci  a  preceding  treatment  with  Kromayer's  quartz 
lamp,  Hollander's  hot-air  method,  or  the  Rontgen  rays  is  to  be 
recommended. 

In  many  cases  these  methods  are  to  be  preceded  by  other 
processes,  even  pyrogallic  acid  treatment,  in  order  to  remove 
beforehand  all  that  weakens  the  effect  of  the  rays,  so  as  to  allow 
them  to  penetrate  to  the  bottom  of  the  proliferations. 

The  older  methods,  excision,  arsenic,  pyrogallic  acid,  &c., 
retain  their  value  as  preparatory  methods,  and  also  where  an  ugly 
scar  does  not  matter  so  much,  as  on  the  trunk  or  extremities.  To 
make  a  right  choice  in  each  case  is  a  matter  of  experience,  and 
success  depends  much  on  the  further  careful  observation  by  which 
a  fresh  growth  will  be  early  recognized. 

In  lupus  of  the  mucous  of  the  nose  it  is  especially  important 
that  a  rational  treatment  should  be  begun  before  it  has  extended 
to  the  external  skin.  The  removal  of  all  diseased  tissue  with  the 
galvano-cautery,  under  cocaine  and  adrenalin,  and  Hollander's 
method  have  proved  very  valuable  in  these  cases  (Gerber  and 
Dresch) ;  careful  observation  after  treatment  must  be  exercised 
(see  also  Alexander,  Freund,  Hiibner,  Jungmann,  Moberg, 
Neisser  and  Meirowsky,  Nied.erstein,  Pforringer,  Scholtz,  Werther 
and  Wichmann). 

In  recent  years,  in  Germany,  the  systematic  combating  of 
lupus  has  been  taken  up  by  the  Lupus  Commission,  in  connection 
with  the  Central  Committee  for  the  combating  of  tuberculosis. 

At  first  for  instruction  110,000  copies  of  Hiibner's  work  "  On 
the  Importance  of  Early  Recognition  in  the  Cure  of  Lupus," 
were  distributed  officially  to  clergymen,  teachers  and  governing 
authorities,  the  school  doctor  was  instructed  by  ministerial  decree 
to  give  information  of  any  case  of  lupus,  and  propaganda  were 
made  in  the  Press  in  connection  with  this  matter,  so  useful  to 
the  public.  The  lupus  patients  registered  at  the  central  station 
were  sent  to  the  nearest  lupus  hospital   for  confirmation  of  the 


-|-iri:i-;AiM:(  I  if  s  399 

diagnosis  .'iiul,  if  ncccssarv,  In  comiii'-iK  <•  I  rc-iiiiifiii ,  and  the 
padenls  vvidioni  nic.-ms,  whose  disease  gave  Iiojjfs  of  cure,  were 
helped.  Im)i  Ihis  |)urpos(;  12,451  marks  were  si^enl  on  121  palienis 
last  year  (1910-11),  and  aboul  lo.fjoo  marks  were  spent  on  inslru- 
ments.  Besides  ihe  Lnj)us  (dinmission  (licrlin  VV.  9,  Konigin 
Aii/^Lislastrasse  11;  I'rcsidcnl,  Alinislcrial-Direclfjr  Professor 
Kirchner),  socielies  exist  in  llambnr^-.  Crandf-nz,  I.auban,  lAf^:- 
nilz,  which  have  llic  conil),-!!  in^;  of  hipiis  on  ihfir  programin'-. 

SCR()FnL()l)l':RMA. 

Injection  of  iodoform  ether  (according  to  Vidal),  or  of  napli- 
thol  camphor,  or  of  chloride  of  zinc  (Lannelongue)  and  pyoktanin 
have  been  recommended  for  scrofuloderma,  but  surgical  treatment, 
witii  the  knife,  thermo-cautery,  or  curette,  are  of  chief  importance. 
Leistikow  had  a  good  result  after  daily  injections  of  iodo-vasogen 
into  the  (caseated)  scrofuloderma  (Friedlander).  Besides  this, 
arsenic  preparations  may  be  employed  internally. 

In    erythema    nodosum    alcohol-turpentine    is,    amongst    oth'tT 
things,  highly  recommended. 

TUBERCULIDES. 

Lichen  scrofulosorum,  as  well  as  tuberculides,  requires  only 
general  treatment,  nothing  locally.  Still  compresses,  or  gentle 
friction  with  cod-liver  oil,  according  to  Vidal-Hebra,  and  the  use 
of  soaps  containing  cod-liver  oil  or  tar,  and  treatment  with 
chrysarobin,  are  advised  as  being  suitable. 

B.— DISEASES   OF    MUCOUS   MEMBRANES. 
RESPIRATORY    ORGANS   AND    PHARYNX. 

Amongst  the  most  frequent  and  most  important  symptoms 
of  scrofulosis  are  adenoid  vegetations.  As  thev  induce  a  series 
of  other  diseases  they  must  be  attacked  as  earlv  as  possible. 
Nose  douches  are  of  little  use,  the  best  thing  is  radical  removal. 

The  operation,  which  is  simple  in  technique  and  not  dan- 
gerous, may  be  performed  on  children  2  rears  of  age  and  even 
younger,  and  is  best  done  before  the  change  of  teeth,  to  avoid 
malformation  of  the  jaws.  It  is  all  the  more  pressingly  indicated 
the  more  secondary  chronic  rhinitis  with  its  consequent  svmptoms 
begins  to  make  itself  troublesome,  and  breathing  through  the 
mouth  favours  bacterial  invasion  (with  frequent  sore  throat) ;  it 
must  not  be  postponed  when  it  has  led  to  disturbance  of  hearing. 


400  SCROl-LLOSIS 

sleep,  appetite,  and  development,  or  even  threatens  to  lead  to 
them  (see  Morse  and  Pfaundler). 

The  operation  must  be  postpt)ne(.l  in  acute  infectious  diseases 
in  the  patient  or  those  around  liim,  and  is  to  be  entirely  avoided 
A\  ith  luemophiles. 

The  removal  of  the  pharyngeal  tonsil  must  naturally  be 
carried  out  Vvilh  sterilized  instruments  (perhaps  after  a  previous 
injection  of  cocaine),  with  the  ring-shaped  knife  of  Beckmann, 
Gottstein,  Lange,  and  others,  or  with  the  cutting  loop. 

The  removal  under  ether  (Griinwald,  Xadoleczny,  Pfaundler, 
-and  Ilecht)  does  not  appear  to  be  indicated  either  in  younger  or 
older  children  (over  4  years,  Bresgen),  neither  is  it  suitable,  as 
the  whole  operation  hardly  lasts  a  few  seconds,  and  therefore 
the  preliminaries  of  narcosis  frighten  the  child  more  than  the 
rapid  operation.  In  the  Belgian  Oto-laryngological  Society,  in 
1909,  most  of  the  specialists  spoke  against  general  narcosis  as 
not  completely  excluding  accidents. 

Reaction  svmptoms  after  the  operation  must  be  combated 
bv  iced  food  and  special  care  for  two  or  three  days,  cold  milk, 
avoidance  of  hot  food,  and  a  nose  douche  with  boric  acid  continued 
for  some  time. 

The  thorough  removal  of  the  Inperplasia  almost  insures 
against  recurrence  (6  to  10  per  cent.)  and  therefore  goes  very  far 
to  avoid  scrofulosis. 

After  the  operatitMi  one  must  convince  oneself  (by  examina- 
tion A\ith  the  linger)  that  nothing  has  remained  behind,  severe 
bleeding  points  to  half-severed  pieces  which  are  hanging  in  the 
pharynx  and  which  must  be  removed. 

With  chronic  rhinitis,  at  the  beginning  of  the  hypertrophic 
stage,  injections  by  means  of  the  nose  douche,  or  spraying  with 
tepid  salt  water,  or  i  to  2  per  cent,  solution  of  bicarbonate  of 
soda,  or  applications  of  a  similar  nature  will,  if  persevered  in, 
attain  the  desired  end;  the  customaiy  drawing-in  of  salt  water 
has  often  induced  catarrh  of  the  middle  ear.  If  of  long  standing 
astringents  are  blown  in  ;  for  example,  pure  boric  acid,  or  menthol 
and  borax  (i  :  10),  or  i  to  2  per  cent,  sozo-iodol  zinc,  or  sozo-iodol 
soda;  later,  argentum  nitr.  o"i  or  0^5  to  10  of  starch  may  be 
used  (but  as  a  precaution  only  on  one  side,  on  account  of  the 
severe  reaction  which  sometimes  follows);  bismuth  subnitr.  (5*0 
to  10  sacch.  lact.),  &c. ;  or  douches  of  bicarbonate  of  sodium, 
borax,  and  sodiimi,  aa  0*4,  and  sacch.  alb.  ro  to  a  tumbler  of 
warm  water  are  recommended. 

Rhagades  are  treated  with  lapis  mitigatus  and  boric  oint- 
ment, scrofulous  ulcerations  with  5  to  10  per  cent,  protargol 
■ointment  (Miiller). 


I  iii';i<Ai'i:i;'iics  401 

I  liavc  loiind  p.'iiiil  iii'^''  willi  Lii^ol's  soluiion  of  Sfi'\  i**;  in 
avoiding  any  loss  of  smell. 

The  IrealnicnL  of  cliionic  n.-isopliaryngfal  ralarrli  is  similar. 
If  the  avoidance;  of  diisl,  ilic  ahslenlion  frc)m  alcoliol  and  \\()i 
spices,  gargling  willi  sail  oi-  ,-dl<.'dinc  walcr,  do  nol  aliain  ihe 
desired  end,  |")ain(ing  willi  glycerin*-,  of  tannin  o"5  or  i  to  if), 
willi  argent.  ni(i-.  i  ov  10  lo  100,  and  especially  soluiion  of  iodide 
of  potassium  in  increasing  strength,  is  resfjried  lo  d;iily  or  every 
second  or  third  day  according  to  ihe  rend  ion. 


IJ  lodi.   puri. 

0'2 

to 

"'3 

lo     0-4 

Pot.    iodidi 

2*o 

)) 

3-0 

n        4-0 

Glyccrini 

JO'O 

)) 

io"o 

,,      lO'O 

01.  menth.  pip.  gtt.  iii. 

vSuccess  is  naturally  conditional  on  making  the  application, 
not  as  frequently  happens  only  to  the  mouth,  hut  lo  the  naso- 
pharynx and  soft  palate,  which  is  often  tlie  seat  oi  I  he  chief 
changes;  it  must  be  applied  with  a  bent  brush,  and  thus  cannot 
be  left  to  the  patient  or  tiiose  around  him. 

Professor  Fasano  speaks  of  really  astonishing  results  with 
zeroform  in  scrofulous  rhinitis.  Ichthyol  as  an  ointment  has 
proved  of  service,  especially  in  rhinitis  with  granulating  crusts; 
it  may  also  be  used  internally  with  aq.  dest.,  equal  parts,  3  to  10 
drops  two  or  three  times  a  day.  Chronic  catarrh  of  the  upper 
respiratory  passages  also  proves  very  amenable  to  sulphur  baths 
and  sulphur  water,  e.g.,  Weilbach  200  to  300  grammes  internally, 
fasting,  or  mineral  baths  with  pinol,  have  excellent  efifect. 

Extensive  thickenings  of  the  nasal  mucous  membrane  and 
hypertrophy  of  the  turbinate  bones  are  cauterized,  after  the  instil- 
lation of  cocaine,  with  trichloracetic  acid  (according  to  Kilian) 
diluted  with  one  drop  of  water,  the  surplus  acid  neutralized  bv 
bicarbonate  of  soda,  or  they  are  burnt  with  the  galvano-cautery, 
either  by  making  three  longitudinal  furrows  (which  it  has  been 
proposed  to  rub  with  trichloracetic  acid),  or  bv  pricks,  which, 
after  inserting  the  cautery  needle  may  be  pushed  still  further 
under  the  mucous  membrane  (the  submucous  method)..  The 
reactive  swelling  after  the  operation  is  subdued  bv  dusting  with 
acidi  boraci  4*0,  cocaini  hydrochlor.  04,  aq.  dest.  ad  200  for 
half  a  minute  three  times  a  day;  the  wound  or  the  scab  must  be 
often  disinfected  by  applying  pure  boric  acid. 

On  account  of  deformity,  often  caused  by  the  application  of 
the  galvano-cautery,  its  use  is  now  generally  replaced  bv  radical 
removal  of  the  turbinated  bones. 

26 


402  SCROFULOSIS 

Polypoid  proliferatit)ns  are  removed  wiili  ihe  eold  or  hot  Nvire 
loop  under  cocaine. 

Granulations  of  the  pharynx  are  cauterized  with  the  lunar 
caustic  point,  chromic  acid  (immediately  neutralized  with  bicar- 
bonate of  soda),  trichloracetic  acid,  or  the  galvano-cautery,  which 
reaches  more  deeply  under  cocaine;  the  after  treatment  is  the  use 
of  antiseptic  gargles. 

In  hypertrophy  of  the  tonsils  the  curved  probe  must  be  passed 
deeply  into  the  lacunae  (according-  to  v.  Hoffmann's  method) 
which  must  be  t)pened  and  painted  with  tincture  of  myrrh  and 
Lugol's  solution.  If,  in  spite  of  this,  frequent  recurrences  of 
sore  throat  take  place,  together  with  respiratory  or  vocal  obstruc- 
tion, the  tonsils  must  be  removed  by  tonsillotomy,  but,  on  account 
t)f  the  carotid  which  lies  beneath,  only  the  portion  made  to  project 
beyond  the  palate  by  drawing  out  the  tonsil  is  removed.  The 
tonsillotome,  pro\  ided  with  prongs,  has  the  advantage  that  more 
can  be  cut  awav,  but  owing  to  the  disadvantage  that  haemorrhage 
is  greater,  man\-  prefer  to  remove  the  tonsils  with  blunt-pointed 
knife  without  drawing  them  out  of  the  cavity,  and  making  the 
incision  from  below  upwards;  others,  again,  use  the  wire  loop. 

Spurting  vessels  are  tied ;  parenchymatous  haemorrhage, 
which  often  occurs  in  anaemic  or  chlorotic  patients,  is  stopped  by 
compression,  or  touched  with  solution  of  ferripyrin  or  hydrogen 
peroxide,  or  even  cauterized  with  the  galvano-cautery  (with  care  !  !) 
Nettelbrock  has  collected  a  hundred  and  fifty  cases  from  the 
literature  of  severe  hasmorrhage  after  tonsillotomy  (Burach). 

As  a  precaution,  w-e  should  always  have  a  Mikulicz's  com- 
pressor ready  to  hand  so  as  not  to  be  at  a  loss  should  haemorrhage 
arise. 

A  few  years  ago  I  performed  tonsillotomy  of  the  left  tonsil 
on  a  woman  of  35  who  was  not  h^emophilic.  Hc'emorrhage 
occurred,  in  spite  of  ice,  of  painting  with  liquor  ferri  and  pressure 
with  plugs  of  cotton-wool  soaked  in  it,  and  which  continued, 
in  spite  of  compression  of  the  carotid,  so  that  I  prepared  to  tie 
the  carotid  from  below  (on  account  of  tonsillotomy) ;  after  eight 
hours  a  long  fainting  fit  put  an  end  to  the  haemorrhage. 

Such  sad  incidents,  which,  fortunately,  are  rare,  may  make 
removal  with  the  galvano-caustic  loop  preferable,  in  spite  of  the 
healing  taking  a  much  longer  time. 

Tonsillotomy  is  contra-indicated  with  h^emophilic  patients, 
in  acute  inflammations,  and  at  the  time  of  epidemics  of  diphtheria 
or  scarlet  fever. 

General  narcosis  is  unnecessary  on  account  of  the  slight  pain 
and  momentary  duration  of  the  operation. 

To  avoid  severe  reaction  after  the  operation,  cold  beverages, 


-mi;KAi'i:(JTics  4*^)3 

fniil,  or  aililK  i;il  i(  <•  may  be  swallowed  ( I  liavc  referred  in  :in(>\\\'tr 
place  lo  my  tinrorimiaie  exijcrienee  wiili  iiaiiiral  river  ice  given 
inlcrnaily,  wliicli  sel  u|)  calarrii  of  I  lie  inieslinrts  and  infeclion  of 
the  wound).  Ice  is  laid  on  I  lie  neck,  resi  in  bed  for  one  (;r  (wo 
days  is  ordered,  and  onl\  eold  (Inid  noiirislimenl  is  given,  milk 
and  raw  eggs,  and  (especially  afur  e\cry  meal)  llie  mrjuth  is  to 
be  well  rinsed  with  2  lo  4  per  cent,  boric  acid,  or  dilnied  hydrogen 
peroxide  lo  avoid   infeclion. 

The  reproach  of  incompleleness  made  againsl  lonsillotomy 
has  a  cerlain  amounl  of  juslilicalion,  as  llu;  siiim|)  left  behind 
frecjuenlly  allows  ihe  entrance  of  germs,  ihere-fore  complete  extir- 
pation has  been  recommended  by  many  (Kopmann,  Sclierenberg, 
Langworthy,  Sturmann,  h^inder,  Kofler,  and  others).  If  this 
radical  operation  be  limited  to  cases  of  constantly  recurring 
severe  inflammation  and  tonsillary  abscesses  (as  in  Ilerzfeld's 
cases),  as  well  as  confirmed  tuberculosis,  this  point  of  view  is  to 
be  considered,  but  I  do  not  consider  it  jusliliable  to  extend  it  much 
further,  for  example,  to  cases  of  simultaneous  swelling  of  the  neck 
glands  (Crokett).  For  in  the  first  place  we  often  obtain  a  com- 
plete cure  by  simple  tonsillotomy,  that  is  to  say,  removal  of  the 
complaint;  secondly,  besides  the  technical  difficulty  of  the  opera- 
tion of  tonsillcclomv,  which  is  proved  bv  the  various  instruments 
and  methods  recommended,  and  which  would  be  the  smallest 
ground  for  prevention,  it  has  often  been  followed  by  severe 
haemorrhage,  which  in  Boston  caused  even  twelve  deaths  in  one 
and  a  half  years.  Also,  it  is  not  yet  demonstrated  whether  the 
stump  which  remains  has  not  some  valuable  function  to  perform. 
Therefore,  taking  everything  into,  consideration  from  our  present 
point  of  view,  a  certain  reserve  must  in  anv  case  be  exercised  as 
to  tonsillectomy. 

In  atrophic  catarrh  resulting  from  hypertrophy  of  the  mucous 
membrane  of  the  nose,  often  of  foetid  character  (ozjena),  our  first 
task  is  the  removal  of  the  foul-smelling  crusts  of  the  secretions  and 
the  scab.  Gottstein's  tampon  serves  this  purpose.  Gottstein's 
screw  probe,  armed  loosely  with  a  cotton-wool  plug  about  the 
thickness  of  the  little  finger,  is  introduced  with  a  spiral  movement 
into  the  nose,  and  again  removed  by  a  spiral  movement  in  the 
opposite  direction,  which  leaves  the  plug  behind.  After  a  quarter 
of  an  hour  to  one  hour  or  more  it  is  withdrawn  with  the  scab  hang- 
ing on  to  it ;  the  remains  of  the  scab  must  be  lightly  washed  awav 
with  about  a  litre  of  fluid  (potas.  permang.  q-i  to  i  litre,  or  2 
to  4  per  cent,  boric  acid,  or  resorcin  i  to  300,  or  alumin.  acet. 
tartar,  ten  drops  to  one  teaspoonful  of  a  20  per  cent,  solution) 
added  to  a  litre  of  water ;  in  case  of  necessity  it  must  be  removed 
with  the  forceps.     This  douche  must  be  first  used  daily,  once  a 


404 


SCROFULOSIS 


clay  when  imprDvemenl  commences,  and  when  the  fcetid  smell 
has  disappeared  a  solution  of  commcMT  salt  or  F.ms  water  may  be 
used;  in  scrofulous  oziuna,  after  rem.ual  of  the  scabs,  dusting 
with  calomel  2-0,  hydrarg.  pra-cip.  nihr.  ro.  amyl.  i5'o  has 
proved  usetul. 

Numberless  remedies  have  been  recommentled  for  oz:ena,  as 
is  always  the  case  with  diseases  whicli  are  the  most  obstinate. 
Recently  Lavrand  has  praised  friction  with  an  ointment  after  the 
removal  of  necrotic  parts  (bism.  sub.  S'o,  vaseline  15-0,  lanolin 
15-0),  which  is  introduced  into  the  depths  of  the  middle  meatus 
of  the  nose  by  means  of  wool  on  the  end  of  a  probe;  by  others, 
thioform,  with  equal  parts  sacch.  lactis,  chinosol,  Buzzi's  sozoiodol 
soap,  naphthalan  (Berthold),  sandalwood  oil  (santyl  knoll,  Menier), 
iodol  (iodol  cryst.,  acid,  tannic,  borax,  aa  5-0.  D.S. — A  pinch 
three  times  into  each  nostril  live  or  six  times  a  day).  Dion  in  lias 
been  often  mentioned  favourably  (or  an  insufflation  with  iodine) 
(Stiel),  while  Dionisio  and  Ranazugi  and  Makie  relate  good  results 
with  Rontgen  rays  (quoted  by  P.  Krause) ;  by  others  paraffin 
treatment  is  recommended. 

Pharyngitis  sicca,  troublesome  on  account  of  the  sensation 
of  dryness  and  the  choking  movements  caused  by  the  dry  and 
firmly  adhering  secretions,  is  favourably  influenced  by  inhalation 
or  spraving  with  2  per  cent,  warm  salt  water,  also  by  painting 
with  glycerine  of  iodide  of  potassiimi  and  iodine,  or  tinct.  caps, 
ann.,  i  or  3  to  50  of  glycerine. 

For  chronic,  and  especially  dry  nasal  and  pharyngeal  catarrh 
and  various  abnormal  sensations,  sometimes  internal  vibration 
massage  recommended  by  Braun,  Lacker,  and  others,  has  ren- 
dered very  satisfactory  service ;  this  is  best  effected  by  means  of 
an  electric  motor. 

If  carious  teeth,  sharp  stumps  or  edges,  or  tartar  erosions 
and  catarrh  are  the  cause  of  it  or  maintain  it  they  must  be  removed. 
Chronic  catarrh  of  the  larynx  is  treated  by  insufflation  of  zinc 
sozoiodol,  or  painting  with  glycerine  of  tannin  2  to  10  per  cent., 
or  nitrate  of  silver  i  or  5  to  100,  and  also  by  inhalation  of  salt  or 
mineral  waters,  as  in  bronchial  catarrh. 

All  catarrhs  of  the  respiratory  passages  are  favourably 
influenced  by  salt,  soda  and  sulphur  waters,  which  we  order  the 
scrofulous  for  other  reasons. 

The  local  treatment  of  all  these  chronic  affections  demands 
much  time  and  patience,  and  it  is  better  to  call  the  attention  of 
the  patient  or  his  relations  to  this  fact  from  the  first.  Thev  have 
also  their  limitatirm  as  to  time;  after  painting  ff)r  two  or  three 
months,  an  interval  is  not  only  a  subjective  benefit  to  the  patient, 
but  often  furthers  the  cure  in  a  surprising  manner. 


-mi;i<Ai'i;i;TK;s  4''\5 

ll  nuisl  1)(^  lakcii  as  a  matlfr  of  coins*-  (yi  a  jjoinl  wliicli  is 
olicn  ncn|c(:lc<l)  iliai  before  every  local  applicalion  (A  medicaments 
llic  mucous  membranes  an-  cleansed  from  rjried  mucus,  crusts,  &c., 
by  rinsin^^  with  lepid  sail  waler,  soliilion  of  soda  (bicarbonate  oi 
soda),  oil  of  almonds  (or  ,:;  per  c(;nl.  solution  of  cresol-iodide),  or 
by  simply  washing  or  s|)raying;  il  is  nol  ihe  mucus  we  want  to 
paint,  but  the  mucous  membrane. 

The  diagnosis  of  rei  lopharyngf-al  abscesses  is  c(m firmed  by 
digital  palpation;  when  llii<  iiiaiion  is  present  they  are  incised  with 
a  knife  covered  witli  slick  in-  plasier,  or  enclosed  in  a  metal  sheath. 
To  avoid  the  aspiration  of  pus  ilie  head  is  bent  forward,  and  the 
child  is  laid  on  its  stomach.  On  account  of  the  vicinity  of  the 
internal  carotid,  the  incision  must  not  be  made  more  than  3  or 
4  mm.  from  the  middle  line.  The  after  treatment  consists  in 
spra\ing  the  pharynx  and  gargling  with  4  per  cent.  l)oric  acid. 

EAR. 

The  most  frecjuenl  form  of  scrofulous  affection  of  the  ear 
passage  is  otitis  media,  the  treatment  of  which  varies  according 
to  its  clinical  form. 

Acute  inflammation  at  the  beginning  or  during  the  course 
of  otitis  needs  to  be  treated  on  general  lines;  rest,  and  if  fever  is 
present,  rest  in  bed ;  confinement  to  the  room  during  cool  weather, 
and  caution  against  taking  cold ;  protection  against  damp  and 
dust  (by  cotton-wool  plugs  in  the  ears),  avoiding  blowing  the 
nose,  so  that  the  secretion  shall  not  be  forced  into  the  ear  and  the 
diseased  tvmpanum  injured;  energetic  antiphlogistic  treatment, 
according  to  the  constitution  of  the  patient,  ice  bags  over  the  ear, 
or  cold  or  moist  and  warm  fomentations  of  plain  water,  or  acetate 
of  aluminium,  or  alcohol ;  two  to  six  leeches  in  front  of  the 
tragus  and  over  the  mastoid  process,  intestinal  derivatives,  and 
aperients. 

For  the  pain,  repeated  rubbing  near  the  ear  with  i  per  cent, 
morphia  ointment;  at  night  and  during  the  dav.  if  there  is  any 
cough,  morphia  or  sulphonal  internallv  ;  instillation  of  8  to  15 
drops  of  a  warm  5  to  10  per  cent,  solution  of  cocaine  (with 
caution,  as  cocaine  in  the  ear  easilv  induces  toxic  symptoms, 
though  these  may  be  transitory,  with  giddiness  and  vomiting) 
(Jacobson) ;  for  troublesome  sensations  in  the  ears  of  a  pulsating 
character,  Lucae's  prescription  is  useful  :  — 

B  Acid,  hydrobrom.    10  per  cent.  ...         ...         ...     20*0 

D.  in  vitr.  nigr. 

S.    20  to  40  drops  three 'times  a  day,  quarter  of  an  tiour  after  meals.    • 
to  be  taken  in  su.£iar-\vater. 


406  SCROFULOSIS 

It.  in  spile  of  this,  the  sensil:)ilily  to  pressure  on  the  skin  and 
swelUno-  over  ihe  masloiel  roniiniu-,  or  maylie  hiq-h  fever,  vic^lent 
headaciie,  '^iddiness  and  oihrr  ihrcau-nini;-  brain  s\mpionis  occur, 
early  paracentesis  of  ilic  i\nipanuni  (hy  a  i^unciurc  3  mm.  brtuKl 
in  the  posterior  lower  quadrant)  must  be  resorted  to  immediately. 
An  early  paracentesis  has  great  advantao^es  over  allowing  th.e 
abscess  to  burst;  postponemcni  may  cause  irreparable  damage 
and  even  threaten  life. 

Rv  emplving  the  abscess  the  troubles  are,  as  a  rule,  rapidly, 
t)flen  immediately,  assuaged;  if  not,  llu-  artificial  or  spontaneous 
opening  is  too  small,  or  has  not  been  made  in  the  right  place,  or 
the  How  of  the  discharge  is  hindered  by  granulations  or  a  polypus, 
or  the  process  has  extended  to  the  periosteum,  the  mastoid,  or  the 
brain.  After  the  paracentesis,  or  rupture,  the  chief  care  is  the 
free  flow  of  the  discharge,  "and  most  careful  cleansing  and 
drying  of  the  ear  passage  "  (Haug).  According  to  the  quantity 
of  secretion,  the  ear  passage  is  cleansed  once  or  twice  daily  with 
sterile  cotton-wool  and  antiseptic  gauze,  or  cotton-wool  plugs  are 
laid  loosely  in  to  soak  up  the  secretion  which  has  collected  in  the 
meanwhile;  this  the  patient  or  parents  must  often  renew  with 
clean  (  !)  fingers.  In  order  that  dried  secretions  shall  not  adhere 
the  ear  passage  may  be  rubbed  with  boric  vaseline  (i  to  15),  which 
at  the  same  time  prevents  erosion  by  the  pus.  The  ear  must  be 
covered  with  a  pad  of  cotton-wool  or  a  moist  warm  bandage;  the 
flow  is  facilitated  by  lying  on  the  side  of  the  affected  ear. 

If  the  secretion  does  not  cease  after  two  or  three  weeks,  or 
the  flow  is  hindered  on  account  of  its  viscid  nature  in  addition, 
a  I  to  3  per  cent,  solution  of  boric  acid  must  be  sprayed  along  the 
outer  ear  passage  gently  by  means  of  a  sterilized  syringe,  the 
solution  being  at  the  body  temperature.  Once  or  twice  daily  the 
ear  passage  must  be  dried  and  plugs  introduced;  in  cold,  bad  and 
windy  weather  the  patient  must  remain  in  the  room  for  at  least 
an  hour  after  the  proceeding. 

Immediately  following  the  spraying,  or  instead  of  it,  iinelv 
powdered  boric  acid  may  be  blown  into  the  ear  daily,  as  long  as 
the  powder  is  dissolved  in  the  secretion,  otherwise  at  longer  inter- 
vals. Only  a  small  quantity  must  be  dusted  in,  so  as  not  to  hinder 
the  secretion  when  the  perforation  is  small  and  granulati(jns 
present;  the  dusting  powder  is  to  be  avoided  for  the  same  reason. 

Drops  of  absolute  alcohol,  95  per  cent.,  may  be  used  dailv, 
once  or  three  times  a  day,  and  should  be  left  in  for  five  or  ten 
minutes  whilst  the  patient  lies  on  the  iieallhy  ear;  they  have 
proved  of  great  value  even  in  foetid  conditions  and  for  the  patient's 
o\yn  use.     The  burning  experienced  at  first  soon  ceases,  but  if  it 


TIIKKAI'ICUTICS  407 

conlimics  llic  .-ilcoliol  111,-iy  Ix'  (liliii<<i  v.iili  hoilfd  v.air-r  (1  lo  3). 
The  alcohol  causes  small  Liivmulnlions  i<.  dis.-ipijcar ;  lav^cr  (^nfs 
must  he  n-movcd  willi  I  riclilor.'icci  ic  ;i(  id,  or  j^ralvano-caulcry, 
polypi  willi  llic  wiif  loop.  insN'ad  ol  nlrdjiol,  or  iijinifdiaU'ly 
after  it,  a  solnlion  ol  j  p'-r  n-ni.  liydroi,'-cn  peroxide  is  very 
valuable. 

Whedier  spraying,  insiifllai  loii,  or  I  lie  drops  he  used,  a 
Sterile  collon-wool  pluj^''  niirsi  he  inirodiKed  ;itier\\ards,  aiul 
changed  when  necessary. 

In  siippuraling  iidlammal  ion  ol  die  e.-n',  besides  die  1  lo  2  per 
cent,  sozoiodol  zinc  solution  (Ivisano),  thioform,  dngenol  (Spitz- 
miiller),  chinosol,  thiol  (by  plugs  and  friction  round  the  ear  with 
li(|uid  diiol  when  diere  is  pain)  are  recommended,  and  zeroform 
for  scrofulous  external   otitis. 

The  local  treatment  must  be  conlinued  as  long  as  suppura- 
tion exists,  Avilh  the  accomj^anying  danger  of  stagnatir)n  and 
decomposition.  When  the  secretion  ceases  every  unnecessary 
irritation  bv  local  treatment  is  to  be  avoided;  only  dry,  clean 
plugs  must  be  introduced  as  long  as  the  perforation  exists,  as  a 
protection  against  dust,  cold  and  damp. 

The  secretion,  which  in  ordinarv  acute  cases  ceases  in  from 
two  to  three  weeks,  lasts  manv  months  in  the  scrofulous,  and  the 
methods  and  remedies  must  be  often  changed.  For  example,  we 
take,  as  a  spray,  a  |-  to  i  per  cent,  solution  of  common  salt,  or,  to 
avoid  foetor,  a  2  per  cent,  solution  (jf  carbolic  acid;  as  a  powder, 
powdered  alum  and  i  to  10  boric  acid  or  iodol  ;  for  insufflation, 
a  2  per  cent,  solution  of  boric  alcohol,  or  a  4  per  cent,  alcoholic 
solution  of  resorcin,  or  the  iodoform  emulsion  recommended  bv 
Urbantschitsch,  especially  for  tuberculous  affections  (iodoform, 
lo'o;  glycerine  8o"o;  aq.  dest.  20'o;  gum  tragacanth,  o'2). 

The  insufflation  of  air  (bv  catheterization,  Politzer's  method, 
or  Luca?'s  dry  douche)  as  an  accessory  for  the  removal  of  the 
secretion  from  the  Eustachian  tube  is  to  be  avoided  as  long  as 
acute  inflammatory  symptoms  exist.  Onlv  one  or  two  weeks  after 
the  complete  disappearance  of  the  secretion,  and  when  using  the 
handkerchief  causes  no  pain — perhaps  sooner  if  there  is  great 
deafness  on  both  sides  (Jacobson) — may  the  air  douche  come  into 
use,  especially  if  the  hearing  is  not  improved,  in  spite  of  damp, 
warm,  absorbent  compresses. 

It  is  repeated  daily,  or  every  two  or  three  davs ;  if  no  improve- 
ment in  hearing  is  found  after  about  four  or  five  weeks,  an  interval 
is  advisable.  Passive  hypera^mia  (by  suction  apparatus)  has 
sometimes  good  results  (Muck  and  others). 

With  coincident  chronic  rhinitis  and  adenoids  the  insufflation 


408  SCROFULOSIS 

of  air  may  only  be  used  after  a  careful  douching,  as  otherwise 
infectious  secretions  may  be  forced  into  the  Eustachian  tube;  it 
is  best  not  to  use  it  in  ozaMia. 

When  ilicrc  are  no  acuie  inllamniaiory  symptoms,  when  we 
have  h>  di>  with  pure  chronic  catarrh  of  the  middle  ear,  the  treat- 
ment is  different. 

'I^-eaimenl  b\-  insuiHalion  of  air,  naturally  \vilh  the  limitations 
necessary  in  rhinitis  (see  above)  is  of  chief  importance;  it  is 
said  to  relieve,  at  least  temporarih-,  the  troubles  c-onsec|uenl  upon 
the  negative  pressure  in  the  ivmpanic  cavity  due  to  the  blockage 
of  the  Eustachian  lube,  and  the  drawing  inwards  of  the  membrana 
tvmpani.  deafness,  &c. ;  and  in  conjunction  with  warm  fomenta- 
tions and  massage  it  furthers  the  absorption  of  the  exudations. 

A\'hen  in  the  moist  form  of  this  catarrh  the  exudations  are 
not  al:>sorbed  after  one  or  two  weeks  (in  spile  of  the  air  in- 
sufflations) on  account  of  their  copiousness  and  \iscid  state,  and 
the  power  of  liearing  is  not  considerably  and  lastingly  improved, 
a  second  ]:)aracentesis  ma\'  even  become  necessary.  The  after 
treatment  in  this  case  is  the  same  as  above,  only  the  opening 
by  paracentesis  is  to  be  immediately  followed  by  several  in- 
sufflations of  air  (Politzer)  to  force  the  secretion  through  the 
incised  opening,  after  which  it  is  remoxed  witli  cotton-wool  or 
forceps. 

As  long  as  discharge  continues  the  insufflation  of  air  is  given 
daily  to  keep  the  paracentesis  incision  open,  and  is  continued  until 
an  improvement  in  hearing  and  an  advancing  increase  of  hearing" 
at  a  distance  is  confirmed.  But  after  five  or  six  weeks  a  pause 
must  be  made;  if  the  improvement  is  not  maintained,  the  insuffla- 
tions mav  be  recommenced  later. 

When  the  discharge  is  very  persistent  and  copious,  Schwartze 
recommends  neutral  ammonia  fumes,  in  statu  nascenti,  with 
Gornperz's  apparatus;  or  turpentine  fumes  when  it  is  scanty; 
warm  water  vapoin-  from  37°  to  50°  C.  mav  be  passed  through 
the  catheter. 

The  prognosis  of  the  dry  form  of  catarrh,  especially  of  a 
scrofulous  nature,  is  far  more  unfavourable.  In  this  form  also 
air  insufflation  is  the  chief  remedy  for  deafness  and  subjective 
sensations  in  the  ear.  Tf  visible  improvement  is  obtained  by  this 
means,  it  is  to  be  used  two  or  three  times  a  day ;  if  no  improve- 
ment is  obtained,  or  anything  more  than  a  momentary  aggravation 
is  noted,  it  must  be  left  off.  In  this  case  the  vapour  of  warm 
water,  or  ammonia,  or  ether,  a  few  drops  of  a  solution  of  5  per 
cent,  bicarbonate  of  soda,  or  a  3  per  cent,  aqueous  solution  of 
chloral  hydrate  is  to  be  introduced  into  the  cavity  of  the  tympanum 


'I  III.RAIM',!;)  ITS  4^>9 

by  means  of  a  callK-lcr,  or  I  )r-lslaii(li'-'s  iiiassfiir  dii  ivinpan,  or 
some  similar  apparatus  is  lo  \)c  used  lo  pr<'\(iii  (ompl'-if  lixaiion 
of  the  auditory  ossicU-s. 

If  a  mastoid  pcrioslilis  should  have  arisen  in  an}  lorm  of 
otitis  media  on  account  of  Ihe  releniion  of  I  he  secretion  llie  cause 
of  this  must  l)e  removed,  ahs(»liilf  resl.  ice  compresses  or  f(nnen- 
tations  and  morphia  pres(  ri!)e(h  II  inipro\ cmenl  does  nol  lake 
place  immediately  and  Hucl nation  is  detectetl,  recourse  must  at 
once  be  had  to  free  incision  (Wilde's  incision). 

If  the  mastoid  cells  are  the  seat  of  siippnrai  ive  inflammation, 
early  scra|)tng  out  of  iIk;  mastoid  process  (in  caries  using  the  sharp 
spoon)  is  indicated.  Fcjr  operative  measures  and  after  treatment, 
see  works  on  the  subject. 

In  every  chronic  otitis  the  nose  and  pharynx  must  be 
thoroughly  examined,  and  catarrh  of  either  cured;  adenoid  vege- 
tations especially  are  to  be  removed. 

Caution  must  be  exercised  with  regard  to  cold  baths  and 
cold  douches  to  the  head  as  long  as  perforations  exist,  diving  is 
to  be  entirely  avoided,  the  entry  of  water  into  the  ears  is  to  be 
avoided  by  cotton-wool  plugs,  or  india-rubber  ear  caps. 

EYE. 

For  eczema,  see  above. 

In  blepharitis  cold  compresses  with  sublimate  solution  (i  lo 
5,000)  or  lead  lotion  may  be  used,  and  where  compression  cannot 
be  borne  10  per  cent,  boric  ointment,  or  painting  with  1-2  or 
5  per  cent,  silver  nitrate,  and  when  necessary  cauterizing  with  the 
nitrate  of  silver  point,  neutralized  by  common  salt  solution,  is 
advisable.     Loose  lashes  should  be  removed  with  care. 

In  conjunctivitis  we  paint  with  silver  nitrate  solution  and 
apply  calomel,  especially  in  the  phlyctenular  form.  In  doing  this 
it  is  best  to  remove  the  coarser  grains  from  the  brush  bv  lightly 
knocking  it,  so  that  only  a  thin  layer  covers  the  conjunctiva  like 
a  veil.  Eisenstein  prefers  finely  powdered  boric  acid;  it  is  softly 
rubbed  in,  and  the  irritation  subdued  by  a  i  per  cent,  solution 
of  cocaine.  When  the  inflammatorv  symptoms  have  subsided 
yellow  precipitate  ointment  (hvdrarg.  oxvd.  flavi,  0*3  ;  vaseline, 
10)  is  introduced  into  the  conjunctival  sac  with  a  clean  glass  rod, 
and  is  lightly  rulobed  on  to  the  lids.  Owing  to  the  great  tendencv 
to  recurrence,  it  is  well  to  continue  the  treatment  for  some  length 
of  time  after  the  cure  of  the  inflammation.  Axenfeld  emphasizes 
scrofulous  inflammation  or  the  eyes  as  being  frequentiv  caused 
by  diplococci  (ascertained  by  examination  of  the  secretion),  which 
only  heals  after  dropping  in   i   per  cent,  solution  of  sulphate  of 


410 


SCROFULOSIS 


zinc  three  times  a  dav  tor  many  wcrks.  ami  the  use  of  zinc  oint- 
ment,   which   is  heller  than  calomel. 

Calomel,  nosophen  and  yellow  precipitate  ointment,  carefully 
prepared  anil  fresh,  are  also  suital)le  for  keratitis.  With  small 
ulcers  on  the  cornea  suppurating-  at  the  hase,  instead  of  calomel, 
we  may  use  warm  fomentations  of  sublimate  solution  (i  to  5,c)<>(') 
three  or  four  times  a  day  for  a  (|uarler  of  an  hour,  or  a  sublimate 
bandage,  but  no  lead  lotion  fomentations,  as  incrustations  may 
form  after  them  (ilciltzke),  or  if  the  intiltration  (-ontiiuic  we  may 
cauterize  with  a  |)oint  of  lapis  mitigatus,  or,  according  to  vSylla 
(Dolschenkow),  with  30  per  cent,  lactic  acid,  in  phlyctenular 
keratitis,  v.  Hoffmann  recommends  amnion,  sulphoichthxol.  a(|. 
destill.  aa  three  times  a  day,  3  to  10  drops  internally;  for  children, 
an  increase  of  drops  corresponding  with  the  years  of  age;  if 
further  complications  arise  it  is  well  to  call  in  a  specialist. 

Photopliobia  and  spasm  of  the  lids  are  eased  by  drops  of  a 
2  per  cent,  solution  of  cocaine  three  or  four  times  a  day,  or  by 
dipping  the  whole  face  for  a  few  seconds  in  cold  water,  or  an  eye- 
bath.  Only  in  cases  of  necessity  may  a  few  drops  of  a  i  per  cent, 
solution  of  atropine  be  introduced;  with  children  this  may  cause 
slight  toxic  symptoms.  For  eczematous  conjunctivitis  with 
photophobia  i  gramme  argvrol  to  40  vaseline  is  recommended. 

Stves  in  the  evelids  are  treated  in  the  usual  way,  with  warm 
fomentations  (of  chlorine  water),  and  then  opened. 

It  is  ver)'  important  to  treat  accompanying  nose  affections 
rationally,  as  scrofulous  eye  diseases  are  often  connected  with 
them. 

For  further  details,  refer  to  vol.  xxi  of  Xothnagel's  manual 
(Schmidt-Rimpler). 

I  would  also  mention  the  recommendation  of  sozoiodol  for 
phlyctenular  conjunctivitis  (Bjelilowskv),  sanoform,  and  thioform 
in  ulcerous  corneal  processes,  naphthalan  in  scrofulous  ophthal- 
mia, iodol  (i  to  2  per  cent,  iodol-vaseline  ointment)  in  blepharitis 
ciliaris,  fibrolysin  for  corneal  opacity,  dionin  in  scrofulous  kera- 
titis and  photophobia,  the  powder  being  laid  on  with  a  camel- 
hair  brush  or  in  solution  (S]3itzmilller). 

C— AFFECTIONS    OF    THE    GLANDS. 

For  the  cure  of  scrofulous  glands  the  preliminar}-  condition 
is  treatment,  and  if  possible  cure,  of  all  affections  which  have 
established  themselves  on  the  skin  and  mucous  membranes  in 
the  area  of  the  sources  of  their  vasa  afferentia. 

Non-tuberculous  adenitis  frequentlv  heals  spontaneously,  even 


-lllliKAI'KlJ'JICS  4'' 

willioul  (lirccl  Irc.'ilmcnl  when  iin  licsli  b.-i(  lcri;il  poison  is  supf'- 
addcd,  and  iIm-  old  poison  is  L^i;i(lii;illy  excrelc^d  l)y  nunabolisni  ; 
Cessanie  causa  ccssaL  ejjcclas.  'I  Inis  we  sff,  for  fxamplf,  lliai 
after  removal  of  llu-  lonsils,  or  (.-nious  \vr\\\,  all  scrofulous 
symptoms  will  oflcn  disappear,  ihou^di  before  diey  li.'id  willistood 
the  most  varied  Ircatnient  (Jcssen,   Dobiscli). 

Bui  when,  besides  the  scrolulons  jjoison,  |jus  ro((  i  have 
entered  the  glands  lliey  may,  wlien  of  weak  virulence,  havj-  dieir 
existence  prolonged  for  an  indelinile  period,  ;ind  die  swelling  of 
the  glands  may  be  dnis  niainlained  and  furdier  areas  become 
affected  by  their  indepentlenl  growili.  In  diese  cases  of  chrr^nic 
non-tuberculous  adenitis  the  healing;-  process  may  be  induced  and 
hastened  by  external  means,  the  so-ialled  separate  treatment. 

For  tiiis  purpose  the  old  remedies — painting  with  iodo- 
potassium  glvcerine,  or  the  stronger  iodine  tincture  weakened  by 
equal  parts  of  tinct.  gallar.,  which  irritates  more — enjoy  greater 
esteem  than  they  deserve;  iodobelladonna  ointment  (potassium 
iodide  2'o,  extr.  belladonna  4*0,  vaseline  \^'<))  and  the  ointment 
with  a  plaster  for  bronchial  glands,  applied  alternately  to  the 
sternal  and  intrascapidar  regions  for  three  days,  have  been  recom- 
mended l\y  Variot. 

The  newer  preparations  (jf  guaiacolvasogen  are  preferable; 
friction  with  iodovasogen,  or  20  per  cent,  creosotevasogen,  25  to 
50  per  cent,  iothion  ointment,  recommended  by  Frey,'  are  stated 
to  have  given  good  results.  Salocreol  frictions  and  paintings 
iiave  been  especially  praised  by  Gnezda,  of  the  Leyden  Clinic 
(8  to  20  grammes  per  dav) ;  naphthalan  has  also  proved  service- 
able, as  has  been  confirmed  bv  manv ;  creosotfukol  has  been 
applied  and  continued  for  some  months  (Hecht). 

Mineral-water  fomentations,  iodine  water  (according  to 
Haller)  sometimes  have  a  favourable  effect,  or  fomentations  of 
sea  water,  which  must  be  filtered,  as  otherwise  it  tends  to  produce 
eczema.  With  an  irritable  skin  inclining  to  eczema  covering 
with  zinc  vaseline  under  compresses  is  to  be  recommended 
(v.  Bergmann).  The  indications  for  mineral  and  sea  baths,  and 
soft  soap  treatment  for  such  cases  have  been  treated  of  above. 

Massage,  electricity,  faradization,  electrolysis.  Genzmer's 
ignipuncture — to  afford  the  caseous  matter  a  wav  of  escape — have 
established  themselves  in  the  treatment  of  these  affections. 

Injections    of    tincture    of    iodine    (5    to    30    drops)    into    die 

^  Frey  orders  a  piece  of  50  per  cent,  iothion  ointment,  the  size  of  a  pea. 
to  be  rubbed  on  the  skin  with  a  glass  spatula  until  it  is  absorbed  (5  to  15 
minutes) ;  before  the  next  rubbing  the  skin  is  to  be  cleansed  with  ether  soap. 


412  SCROFILOSIS 

diseased  parenchyma,  according  to  Demme,  Richelot  and  Bradley, 
and  3  per  cent,  carbolic  acid  (lo  to  20  drops),  accordino-  to  llueter, 
Schiiller's  10  per  cent,  iodoform  ether  and  Demnic's  suhculanet)us 
discissions  are  to-day  generally  abandoncil.  Oiiiz  somelinies 
obtained  healing  or  improAenienl  after  injections  of  naphthol 
camphor  three  or  four  limes  a  day  with  intrr\als  ot  ivn  lo  fifteen 
days. 

GoihI  results  are  reported  b\-  Bergonie  from  the  Rdntgen 
ravs,  both  with  superficial  and  deep-seated  tuberculous  glands; 
with  caseated  glands,  as  well  as  with  suppurative  and  discharging 
glands,  the  success  (according  lo  P.  Krause)  is  very  slight, 
though  now  and  again  the  fistuke  disappear.  Recently  longer 
application  of  the  Rontgen  rays  has  been  recommended,  even  fo 
the  production  of  slight  erythema  of  the  skin.  Belot,  Bergonie, 
Barjon,  v.  Gardiner,  Pfahler,  Ferrand  and  KrouchkoU,  Mayes, 
and  Wetterer  mention  good,  sometimes  brilliant  results,  in  which 
a  favourable  cosmetic  appearance  is  also  noticed ;  Mahat  has 
obtained  cures  in  non-suppurating  glands  by  high  doses,  and 
sittings  at  long  intervals,  in  two-thirds  of  the  cases  after  two  or 
tliree  months ;  other  reports  are  less  satisfactory,  especially  the 
occurrence  of  general  miliary  tuberculosis,  or  the  further  spread 
of  the  tuberculosis  has  often  been  observed  after  the  radiation 
of  tuberculous  glands  (Stein wand,  Gemari  [quoted  from  Krause], 
Caccia  and  Francioni)  and  complications  from  severe  fibrinous 
pleurisy  (Ouadrone).  Great  care  is  especially  necessary  with 
suppurating  glands.  Wilms  emptied  caseous  matter  and  pus 
from  a  small  wound,  and  then  obtained  a  very  good  scar  by 
Rontgen  radiation.  Heliotherapy  also  brings  about  good  results 
in  tuberculosis  of  the  glands  (see  pp.  330  and  342). 

Domenici  and  Cheron  mention  having  obtained  improvement 
and  cure  of  chronic  glandular  swellings  by  laying  silver  tubes 
containing  radium  sulphate  in  the  tuberculous  tissue. 

We  must  also  just  mention  the  recommendation  by  Bernheim 
of  dioradin  (radio-active  iodomenthol)  for  tuberculosis  of  the 
glands. 

If  in  the  further  course  another  invasion  of  bacteria  of  high 
virulence  should  induce  active  inflammatory  symptoms,  generally 
of  an  acute  nature,  at  the  periphery  they  are  to  be  combated  by 
antiphlogistic  treatment,  ice,  and  Leiter's  cold  coil.  As  soon  as 
fluctuation  can  be  detected  and  rapid  inflammatory  involvement  of 
the  skin  takes  place,  an  incision  is  to  be  made  without  waiting  for 
spontaneous  rupture  ;  it  must  be  made  wide,  especially  when  phleg- 
monous characteristics  are  present;  besides  this,  care  must  be 
taken,  on  account  of  the  youth  of  the  patient,  to  avoid  as  far  as 


I  iii';i<Ai'i';in  k;s  4'3 

possibl*;  iIh-  cliicf  1)1(m)<1-vc.ss<'Is,  so  as  lo  liav<-  liiiK;  bl'-<-<ling, 
and  in  the  deeper  layers  to  niak<-  ili<-  preparatory  incision  will) 
a  blunt  knife.  By  following  ilic  ruh-s  given  under  general 
surgical  after-ircalnicnl  llx-  process  soon  lic;ils  after  careful  arrest 
of  lu'emorrhagc^  by  iigalures  .ind  pressure,  wiili  drainage  wlien 
necessary;  sometimes  undermined  ne(  roijc  edges  of  sU'in  must  l)e 
removed,  and  shreds  of  tissue  or  weak  granulat  i<.ns  must  be 
treated  with  the  sharp  spoon. 

vShould  the  glandular  tumour  be,  /)/  lolo  or  in  pcirlc,  of  a 
tuberculous  nature,  whether  primarily  or  should  it  become  so 
while  under  observation,  besides  the  treatment  at  the  periphery 
(point  of  entry),  to  avoid  further  infection  it  would  appear  the 
most  rational  course  to  eradicate  (he  affected  gland,  root  and 
branch,  and  with  it  the  germ  of  severe  con.sequent  conditions, 
in  view  of  the  frequent~'furlher  dispersal  of  the  bacilli  which  have 
entered  not  only  to  other  groups  of  glands,  but  also  to  the  lungs, 
the  bones,  and  in  the  form  of  miliary  tuberculosis  over  the 
whole  body. 

Hueter  is  most  stronglv  in  favour  of  total  extirpation.  With 
tumours  the  size  of  a  walnut,  he  says  the  surest  remedy  is  "  not 
iron  in  solution,  in  mixtures,  but  iron  in  sharpened  form — the 
knife,"  and  if  in  twentv  such  cases  operated  upon  only  a  single 
one  would  have  de\'eloped  miliary  tuberculosis  without  operation, 
that  would  be  reason  enough  for  performing  it,  especially  as  with 
the  nineteen  others  the  cure  is  attained  more  rapidly  than  without 
operation.  Poulet,  Most,  Bouilly,  Chretien,  Marfan,  Treves,  and 
others,  are  also  advocates  of  total  extirpation,  and  have  obtained 
apparently  good  results  with  it  (see  also  Syms,  Much,  and  Beyer). 
O.  V.  Angerer  recommends  total  extirpation  most  warmlv. 

The  statistics  brought  forward,  as  proof  of  favourable  lasting 
success,  are  for  the  greater  part  as  good  as  worthless,  but  so  are 
also  the  statistics  to  the  contrarv,  which  are  intended  to  represent 
the  evils  of  extirpation. 

When  the  statistics  brought  forward  in  support  of  extirpa- 
tion give  the  ultimate  result  of  127  out  of  297  cases  treated,  and 
other  statistics  brought  forward  against  its  use  only  give  the 
ultimate  result  of  48  cases  out  of  12S  extirpations,  no  opinion 
can  possibly  be  based  on  this.  For  only  vague  surmises  can  be 
formed  of  the  remaining  cases,  which  form  more  than  half,  nearlv 
two-thirds  of  the  total ;  the  patients  may  have  withdrawn  them- 
selves from  control  because  they  felt  too  well,  but  just  as  probablv 
because  they  were  covered  by  the  cool  turf  !  It  is  quite  uncertain 
how  they  would  have  altered  the  result  if  they  had  been  reckoned, 
perhaps  they  would  have  changed  it  to  the  opposite. 


414 


SCROFULOSIS 


Certain  practical  doubts  have  been  urged  on  principle 
respecting-  total  extirpation,  though  ii  appears  theoretically  justi- 
rtable.  v.  Bergniann  sees  a  danger  in  the  often  unavoidable 
hcemorrhage  "  to  which  children,  under  lo  years  of  age  especially, 
react  verv  sensitivelv,"  and  to  which  badly  nourished  scrofulous 
children  fail  completely  to  react;  also  there  is  the  impossibility 
in  the  case  of  extensive  swelling  of  removing  all  the  caseous 
matter  and  so  excluding  the  frequent  starting-point  of  suppura- 
tion, of  infection  and  the  cause  of  repeated  operations;  lastly,  the 
difTicultv  of  arranging  constricting  bandages  on  the  movable  neck, 
as  can  be  done  on  the  trunk  or  extremities. 

Recently  Pottenger,  Pilip  and  Albert  Robin  have  expressed 
themselves  against  the  removal  of  tuberculous  glands,  chiefly  for 
the  reason  that  glands  out  of  sight  might  be  affected,  and  therefore 
the  extirpation  of  manifest  glands  would  not  be  any  protection 
against  recurrence. 

In  further  support  of  the  conservative  treatment  up  to  a 
certain  limit  I  should  like  to  add  what  I  have  already  emphasized 
before  (pp.  127  and  220),  that  hardly  any  other  organ  of  the  body 
is  in  so  advantageous  a  position  for  arrest  of  tuberculosis  as  the 
lymph  glands,  because,  on  account  of  the  capsule  which  encloses 
it  so  firmly,  the  tuberculous  toxin  is  often  held  in  concentration, 
which  suffices  to  irritate  the  periphery  to  an  inflammatory  limiting 
boundary.  Frequently  only  very  considerable  causes,  for  example, 
inflammatory  saturation  after  measles  or  traumatic  irritation,  is 
needed  to  mobilize  the  enclosed  bacilli. 

I  cannot  repress  the  suspicion  that  this  iraimiatic  irritation 
is  not  so  very  rare,  and  is  even  given  by  the  too  busy  hand  of 
the  doctor,  who,  by  repeatedly  palpating  to  discover  the  situation 
of  the  gland  and  its  size  or  fluctuation,  often  exercises  too  great 
pressure  on  the  tense  morbidly  disposed  gland,  and  so  through 
the  few  outlets  which  remain  open  a  few^  germs  are  sometimes 
pressed  out  and  carried  into  new  channels,  unconsciously  the 
further  dispersal  is  thereby  advanced.  It  is  with  difficulty  that 
we  come  to  a  knowledge  of  the  etiological  connection,  as  it  is 
only  after  weeks  and  months  that  the  sad  consequences  are  per- 
ceptible, and  they  are  then  put  down  to  natural  further  dissemina- 
tion. For  this  reason  I  would  warn  against  an\  heavy  massage, 
and  especially  against  pressure  bandages,  which  were  formerly 
used  wath  very  serious  consequences,  and  recommend  that  any 
pressure  or  squeezing  which  is  not  absolutely  necessary  be  avoided 
during  the  operation. 

That  which  has  especially  supported  total  extirpation,  namely, 
the  fear  of  infection  of  the  lungs  through  the  glands,  appears  after 


'riii:KAri;i;i  ics  41.5 

our  former  statements  (see  p.  U)\),  il  noi  f-ntirely  unjustifiable,  at 
least  t(j  be  very  much  exaggeratc^ci,  tor  in  lli(i  (;as(,'S  vvln;re,  with 
or  after  tuberculosis  of  the  neck  and  oIIkt  glands,  pulmonary 
tuberculosis  has  ap|)eared,  as  a  rule,  \\(;  lia\c  lo  do  with  a  second 
independent  infection  of  the  lungs  from  ouisidc,  and  arising  from 
the  same  centre  of  infection  as  the  cervii  al   1  nberculosis. 

On  the  whole,  ihcrcforc,  we  musi  noi  be  too  hasty  vvilh  total 
extirpation,  as  we  know  that  a  considerable  part  of  gland  tuber- 
culosis is  caused  by  the  bovine  ba(  diu.s,  the  changes  caused  by 
which,  especially  in  older  cliildren,  retrogress  spontaneously,  and 
therefore  surgical  treatment,  which  is  unfortunate  if  only  from 
cosmetic  considerations,  appears  frequently  to  be  unnecessary. 

These  doubts  are  naturally  increased  when  we  consider  the 
removal  of  the  mesenteric  glands,  which  is  much  more  serious, 
but  which  might  become  necessary  in  the  case  of  palpable  tumours 
(see  Stark,  Edred  Corner,  and  Thiemann). 

According  to  v.  Bergmann  extirpation  (A  the  cervical  glands 
is  only  indicated  :  (i)  "  When  a  single  gland  has  grown  to  a 
considerable  size."  (2)  "  When  one  or  more  groups  of  glands 
resists  general  treatment  and  increases  in  size,  as  long  as  peri- 
glandular inflammation  is  not  superadded."  Under  these  con- 
ditions the  gland  may  be  lifted  from  its  position  ;  the  operation 
is  easy  and  not  dangerous  if  severe  haemorrhage  is  not  threatened 
bv  adhesions  to  the  walls  of  the  vessels. 

In  my  opinion  extirpation  must  be  seriously  considered  when 
traces  of  softening  are  evident,  but  not  if  extensive  adhesions  are 
threatened,  for  it  is  just  in  the  softening  stage  that  the  danger 
of  the  bacilli  being  carried  further  threatens  most,  and  which, 
apart  from  a  better  scar,  is  earlier  and  more  completely  met  bv 
extirpation  than  by  incision. 

When  abscess  formation  and  demonstrable  fluctuation  occur 
the  contents  are  aspirated  with  a  syringe  and  i'5  iodoform  vasogen 
is  injected,  or  an  incision  is  made  and  the  caseous  mass  and 
abscess  membrane  are  scraped  with  a  sharp  spoon.  Open  wounds 
are  covered  with  dermatol  pow'der  and  gauze,  or  iodoform,  or 
one  of  the  substitutes  for  iodoform.  In  the  case  of  fistulse  Rabl's 
proceeding  may  be  employed,  breaking  off  nitrate  of  silver  fila- 
ments about  the  thickness  of  a  pin  into  the  fistula?  and  letting: 
them  remain  there  after  the  surrounding  parts  have  been 
thoroughly  smeared  with  vaseline  to  avoid  their  being  cauterized. 
I  have  convinced  myself  in  a  few  cases  that  this  method  is  pro- 
ductive of  very  favourable  results. 

The  discussion  of  various  points  does  not  belong  to  the  scope 
of  this  book ;  such  are  :   The  method  of  operation  in  extirpation 


4l6  SCROFULOSIS 

and  incision;  the  line  of  the  incision  with  a  view  to  the  scar; 
Doilinger's  method  of  subcutaneous  removal  of  the  glands  from 
the  back  of  the  neck;  the  lifting  out  of  the  gland;  avoidance  or 
ligature  of  vessels;  the  section  of  the  internal  jugular  vein,  which 
mav  become  necessary;  the  conneclioi>  of  the  facial  branches  with 
submaxillarv  glands;  the  principles  of  after-treatment.  On  all 
these  points  1  refer  to  surgical  manuals  and  to  Angerer's  treatise 
in  Pentzoldt-Stintzing's  Manual,  vol.  ii.  Bier's  congestion 
method  has  sometimes  proved  advantageous  in  after-treatment 
(see  also  Mohr). 

D.— SCROFULOSIS    OF    THE    BONES    AND    JOINTS. 

In  recent  vears,  in  scr(ifu!n-iul)erculous  bone  and  joint 
diseases,  as  in  tuberculosis  of  the  glands,  the  conservative  treat- 
ment claimed  by  Rabl  and  others,  as  the  result  of  great  experience 
and  such  as  is  practised  in  the  largest  hospital  for  scrofulosis  at 
Berc-sur-mer,  has  gained  more  and  more  ground.  Many  only 
operate  in  isolated  bone  tuberculosis  (Vogelmann).  Hoffa,  Bier, 
Klapp,  Murphy,  and  manv  others  favour  it  more  decidedly. 
Garre  admits  an  indication  for  operation  on  general  grounds, 
when  external  circumstances  do  not  admit  of  the  use  of  other 
means  of  cure.  Surgical  treatment,  resection  and  the  sharp  spoon 
are  to  be  avoided  as  far  as  may  be,  unless  septic  mixed  infection, 
hectic  fever,  or  other  evils  collectively,  imperatively  demand  such 
intervention.  The  most  important  points  in  treatment  are  a 
restful  position,  especially  of  the  affected  region  of  the  body, 
fixation,  immobilizing  bandages  or  extension  bandages  to  relieve 
the  affected  joint ;  in  spondylitis  a  plaster-of-Paris  jacket,  or  the 
Calot  corset  with  gentle  tightening  (Rosenberger's  cheap  gelatine 
corset),  and  bandages  for  walking,  which  are  a  further  develop- 
ment of  Hessing's  bandages,  which  permit  the  patient  to  exercise 
in  the  open  air.  Tt  has  been  proved  tliat  by  these  means  a  large 
number  of  cases  in  which  formerly  resection  would  have  been  con- 
sidered necessary  have  healed  well,  indeed,  better  than  formerly. 

Undoubtedly  the  method  requires  a  long  time  and  much  care. 
Thus  treatment  for  spondylitis  in  a  plaster  jacket  extends  over 
a  year,  and  children  with  tuberculosis  of  the  hip-joint  may,  when 
all  acute  symptoms  have  ceased  often  for  a  vear  or  more,  only 
move  on  crutches  with  a  high  boot  on  the  healthy  foot  to  save 
the  diseased  joint.  But  the  results  are  very  satisfactory,  especially 
when  mineral  and  sea  baths,  soft-soap  treatment,  climatic  treat- 
ment, good  nourishment,  iron  and  cod-liver  oil,  &c.,  raise  the 
general  powers  of  resistance  of  the  body  at  the  same  time;  there- 


THHRAl'KUTICS  4' 7 

fore  sucli  cliildrcn  arc  best  sent  away  from  llif;  municipal  liospilals 
to  cliildrfn's  liospilals.  I'lvcn  wIm'ii  grealer  surgical  inl(;rf<T<'n<(; 
appears  necessary  ii  is  iireciil  ilial  llie  children  should  he 
strenglhened  beforehand  by  a  climalic,  and  baih  trealmenl. 

The  so-cahed  anoperaLion  is  in  very  evil  od(;ur,  as,  unless  all 
thai  is  tuberculous  is  removed  from  I  he  heafthy  tissues,  a  dispersal 
of  the  bacilli  in  the  body  may  easily  take  place. 

Acute  abscesses  are  lanced,  but  cold  abscesses  are  in  general 
better  only  punctured  so  as  to  avoid  as  far  as  possible  secondary 
infection,    which    is  one  of  the  chief  dangers  of  surgical   tuber- 
culosis.    Spondylitic   abscesses,    which    Menard   and    Goldmann 
especially  note  and  which  often  lead  to  paralysis,  must  be  opened. 
The  good  repute   in   which    lo  per  cent,   iodoform  glycerine 
solution  stands  holds  good  in  the  case  of  fistula;,  cold  abscesses 
and  joint  tuberculosis  (Hoffa,  Tietze,  and  Renard),  and  is  only 
questioned  by  a  few  (Bowlby) ;  a  lo  per  cent,  iothion  ointment  is 
preferred  by  many  (Hauser  and  others).     In  tuberculosis  of  the 
glands  and  joints  Lannelongue,  Calot,  and  others,  inject  guaiacol, 
creosote,  iodoformol  (or  oil  6o'o,  ether  40*0,  creosote  4'o,  iodoform 
lo'o),  as  soon  as  the  abscess  is  ripe,  and  before  that,  camphor- 
naphthol  glycerine.    Wreden  also  recommends  naphthol  camphor 
I  to  2  per  cent,  (with  i  per  cent,  cocaine  beforehand)  for  fistuhe  and 
abscess  cavities ;  or  for  interstitial  injections,   camphor-naphthol 
glycerine  i  to  2-5.     Recently,  instead  of  iodoform  glycerine,  injec- 
tions of  I  per  cent,  trvpsin  (Fairchild  Brothers  and  Foster)  may 
be  tried  to   induce   digestion   of   the  pus   and   to   encourage   the 
blocked  absorption  products  to  flow.     The  injection  of  i  to  2  c.c. 
into    the    diseased    tissues    is    given    every    six    or    eight    davs. 
Baetzner   and  Jochmann    had    good    results  with   this   in    Bier's 
clinic  in  cases  of  severe  bone  and  joint  tuberculosis,  as  had  also 
Kantorowicz,    Borsecky  and   Turan,    Schiller   and  others,    while 
Bruning,  Sohler  and  Brandes  obtained  less  satisfactory  results; 
sometimes  joint  tuberculosis  with   large  foci  and  caseated   Ivm- 
phomata  exclude  the  use  of  trypsin. 

Carbenzym,  carbon,  trypsin  as  injection  or  as  powder,  for 
sprinkling  wounds  which  heal  badly,  have  proved  useful,  accord- 
ing to  zur  Verth,  Falk,  and  Sticher. 

Of  more  recent  remedies  for  use  in  scrofulous  bone  and  joint 
affections  the  following  are  recommended  :  sanoform,  chinosol. 
sozoiodol  salts,  iodoformogen,  iodofan,  xeroform,  thioform,  per- 
hydrol,  alsol  (lenicet),  leucofermantin,  &c.,  and  soap  injections 
(Delrez). 

We  have  already  referred  above  (pp.  330  and  342)  to  the  good 

27 


4lS  SCROFULOSIS 

results  of  sunlight  radiation  carried  out  methodically  on  the  plan 
instituted  in  Leysin. 

Treatment  by  active  and  passive  hyperiemia,  according  lo 
Bier,  also  renders  good  service  in  many  cases  with  proper  tech- 
nique and  selection  ;  short  periods  of  congestion,  for  one  to  two 
hours  daily,  until  the  appearance  of  a  deep  red  acute  form  of 
inflammation  shows  itself,  but  without  pain  and  oedema,  with 
an  interval  of  a  week  after  three  or  four  weeks,  have  proved  very 
^iseful  especially  in  fistulous  and  suppurating  tuberculosis. 

Deutsclilander,  Chaput  (twelve  hours'  congestion  bandage) 
and  others  emphasize  the  value  of  congestion.  Konig  warns 
against  exaggerated  expectations ;  Delbet,  Renon,  Tuf!ier  and 
Quenu  have  an  unfavourable  opinion  of  the  method. 

Successes  are  also  recorded  by  Rontgen  radiations  in  bone 
and  joint  tuberculosis  (Freund,  Gregor,  Pavli,  B(!>cl^re,  Rudis- 
Jacinski,   and  others). 

Recently  intense  radiation  by  Wilms's  method  (hard  tubes, 
radiation  of  one  hour,  w-ith  prevention  of  the  soft  rays,  by  means 
of  an  aluminium  filter)  has  been  preferred.  P.  Krause  warns 
against  too  energetic  application,  and  expresses  himself  more  in 
favour  of  smaller  doses  (about  half  the  dose,  suf^cient  to  produce 
erythema,  according  to  Kienbock)  with  repetition  after  fourteen 
days. 

Denks  and  others  record  (in  five  cases)  good  results  in  bone 
tuberculosis  by  treating  with  strong  Rontgen  light  according  to 
Iselin's  method  in   Bale. 

For  the  technique  of  each  measure  and  for  the  method  of 
operation  for  resection  and  amputation  I  must  refer  to  surgical 
manuals  (see  also  Correa,  v.  Dorp,  Karewski,  Klapp,  Miller, 
Warren  Low,  Plate,  Rosenberger,  Sarfels,  Schanz,  Tietze,  and 
Verneuil). 


ABBREVIATIONS    USED    IN    THE 
BIBLIOGRAPHY. 


Allgcmcine  Wiener  mcdizinische  Zci- 
luiig     ...  

Alter  Hygienische  Rundschau 

Annales 

Annales  d'liygiene  publique  et  de  mede- 
cine  pratique 

Arcliiv  fiir  Anatomic  und  Physiologie  ... 

Archiv   fiir   Augenheilkunde 

Archiv  fiir  Dermatologie  und  Syphilis  ... 

Archiv    fiir  Kindcrheilkunde 

Archiv   fiir  klinische  Chirurgie     

Archiv   fiir  klinische   Medizin 

Archiv    fiir   Ohrenheilkunde  

Arztliches  Intelligenzblatt 

Band 

Baumgartens  Jahresbericht  liber  die 
Fortschritte  in  der  Lehre  von  den 
pathogenen   Mikroorganismen   ... 

Beitrage  zur  experimentelle  Pathologie 
und    Therapie 

Beitrage  zur  experimentellen  Therapie  ... 

Berliner  klinische  Wochenschrift 

Brauers  Beitrage  zur  Klinik  der  Tuber- 
kulose 

Bristol  Medico-Chirurgical  Journal 

British  Medical  Journal 

Bruns  Beitrage  zur  klinischen  Chirurgie 

Bulletin  de  la  Societe  frangaise  de  Der- 
matologie 

Comptes-rendus  de  I'Academie  des 
Sciences 

Comptes-rendus  de  la  Societe  de  Bio- 
logic 

Comptes-rendus  de  la  Societe  Medicale 
des   Hopitaux 

Dermatologische   Zeitschrift  

Deutsche  mcdizinische  Wochenschrift  ... 

Deutsche    Medizinalzeitung 

Deutsche  Monatsschrift  fiir  Zahnheil- 
kunde 

Deutsche  Vierteljahrsschrift  fiir  offent- 
lichc   Gesundheitspflege   ... 

Deutsche  Zeitschrift  fiir  Chirurgie 

Dissertation 

Fortschritte   der   INIedizin 

Gazette 

Gazette  des  Hopitaux 

Gazette  Medicale  de  Paris  ...         

Gerhardts  Handbuch  der  Kindcrheil- 
kunde 


Allg.  W.  m.   Z. 
y\lter.   Hyg.  R. 
Ann. 

Ann.  d'hyg.  publ.  et  de  med.  prat. 

A.  f.  Anat.  u.  Physiol. 

A.  f.  Augenhlk. 

A.  f.  D. 

A.  f.  Kdhlk. 

A.  f.  kl.  Ch. 

A.  f.  kl.  Med. 

A.  f.  O. 

Arztl.  Intelligenzbl. 

Bd. 


Baumg.  Jb. 

Btr.  exp.  Path.  u.  Ther. 
Btr.  z.  exp.  Path.  u.  Ther. 
B.  kl.  W. 

Beitr.   z.  Kl.  d.   Tub. 
Bristol  Med.-Chir.   Journ. 
Brit.  Med.  Journ. 
Btr.  z.  kl.  Ch. 

Bull.  Soc.  fr.  de  Dermat. 

C.-r.  Acad.   sc. 

C.-r.  soc.  biol. 

C.-r.  soc.  med.  hop. 
Derm.  Z. 
D.  m.  W. 
D.  M.  Z. 

D.  Mschr.  f.  Zhlk. 

D.  Vi.  f.  off.  G. 

D.   Chir. 

Diss. 

F.  d.  M. 

Gaz. 

Gaz.  des  hop. 

Gaz.  med.   de  Paris. 

Gerhardts  Handb.  d.  Kinderk. 


420 


SCKOFULOSIS 


Heft        

Hygienischc    Rundschau 
Jcihrbucli 

Jalirbuch    fiir   Kinderheilkunde     

Journal  ...  ...  ...  ... 

Journal   e>f   the  American   jNIedical  Asso- 
ciation 
Journal  of  Cutaneous  and  Genito-urinary 

Diseases,    New   York        ...         

Journal  of  Infectious  Diseases     ... 
Journal  de  IMedccine  et  de  Chirurgie    ... 
Journal  de  Medecine  veterinaire 
Journal  medicalc  de  Bruxelles    ... 
klinischer    Band 

Klinischcs  Jahrbuch  ...         

Klinische    Monatsblatter    fiir    Augenheil- 

kunde    (Zehender)  

Korrespondcnzblatt  ...         ... 

Korrcspondcnzblatt  fiir  Schweizer  Arzte 

La   Medecine   Moderne        

Medical    News 

Medical  Record,   New  York 

Medical   Times  

Medizinische  Klinik  ...         ...         

Mitteilungen    aus    deni    kaiscrlichen    Ge- 

sundheitsamt 
Monatshefte  fiir  praktische  Dermatologie 
Monatsschrift  fiir  Kinderheilkunde 
Ivliinchcner  medizinische  Wochenschvift 
Nouvelle  Iconographie  de  la  Saltpctriore 
Pediatric  pratique   de   Lille 
Practical    Medicine    ... 
Prager  medizinische   Wochenschrift 
Prager  Viertcljahrsschrift    fiir   die   prak- 
tische  Heilkunde    ... 
Progres   medical 
Revue 

Revue  de  medecine  de  Paris 
Revue      mensuelle      des      Maladies      de 

I'Enfance 
Revue  de  la  Tuberculose    ... 
Rivista  di  Clinica  Pediatria 
Sammlung     klinischer     Vortrage     (Volk- 

mann) 
Semaine   medicale 

Societe   medicale   des   Hopitaux 

Therapeutische    Monatshefte 

Die  Therapie   der  Gegenwart       

Tierarztliche    "Wochenschrift 

L'Union   medicale 

Verhandlungen    der    pathologischen    Ge- 

'iellschaft 
Vierteljahrsschrift  fiir  Dermatologie  und 

Syphilis 
Viertcljahrsschrift     fiir      die      praktische 

Heilkunde    (Prag)  

Virchows    Archiv 

Virchow-Hirsch,    Jahrcsbericht    iiber    die 
Fortschritte  der  gcsamten  Medizin     ... 
Wiener  klinische  Wochenschrift 
Wiener    medizinische    Blatter 
Wiener  medizinische   Presse 
Wiener  medizinische  Wochenschrift       ... 
Zeitschrift    fiir    Hygiene  und   Infektions- 
krankhoiten  ... 

Zeitschrift   fiir  ITvgienc       

Zeitschrift  fiir  klinische  Medizin 


H. 

Hyg.  R. 

Jb. 

Jb.  f.  Kdhlk. 

Journ. 

Journ.  .\mcr.  Med.  Assoc. 

J.  .of  Cut.   Dis. 

Journ.  of  Infec.   Dis. 

Journ.  de  Med.  et  de  Chir. 

Journ.  de  m.  vet. 

Journ.    med.    de   Bruxelles. 

Kl.  Bd. 

Kl.  Jb. 

Kl.  M.  f.  Aughlk. 
Korr. 

Korr.  f.  Schw.  A. 
La  med.  mod. 
Med.   News. 
Med.  Rec. 
Med.  Times. 
Med.   Kl. 

M.  kais.  G.  A. 

Mh.  f.  pr.  D. 

Mtschr.  f.  Kdhlk. 

M.  m.  W. 

Nouv.  Iconogr.  de  la  Salpetriere. 

Pediat.  prat.  Lille. 

Pr.  med. 

Pr.    m.    W. 

Pr.  Vj. 

Progres  med. 

R. 

R.  de  m.  Paris. 

Rev.  mens  des  malad.  de  I'enf. 
Rev.  de  la  Tb. 
Riv.  di  Clin.   Pcd. 

Samml.   kl.    Vortr. 

Sem.   med. 

Soc.  med.  des  hop. 

Th.  Mh. 

Th.   d.  Gegenw. 

Tierarztl.   W. 

Un.  m. 

Verb.  d.  path.  Ges. 

Vj.  f.  D. 
V.  A. 

V.  H. 

Pr.  Z.  f.  Hlk. 
W.  kl.   W. 
W.  m.  Bl. 
W.  m.  Pr. 
\y.  m.  W. 

Z.  f.  H. 
7.    f.   HviT. 
Z.  f.  kl.'M. 


AUKUKVIAI'IONS    USKI)    IN    I  i  1 1'.    l5H',l,IO(  .K  \l'l  I Y 


421 


l';ith. 


Zeitschril't    fiir    ( Jlircnlicilkuiirlr /,.    f.    O. 

Zeitsr.hrift    Jui;    diiUctihcljc   liJid    i)ljysik;i,- 

lische  Thcrapie      ...         ...         ...         ...  /.  f.  diiii.  u.  jilivhik-.  Ther. 

Zeitsclirift  fiii'  Tuberculosa  ...         ...  Z.   f.  Tl;. 

Zeitschrifl:    fur   Znlmlicilkuiulc      /,    I,   /lilk. 

Zentralbkitl; /Id. 

ZentralbhiU     fiir     ;i.l  iKi'inciiic     I'jitlujIoKK' 

und  palboloKisrlu;  Anjitomic      ...  ...  '/.U\.    I 

Zentralbhilt   fiir   ILaktcricdogic  und   J'ara- 

sitenkundc  ...  ...  ...  ...  /Id.   f.    I'.. 

Zentralbl.itt    fiir    Chirurgie  /Id.   f.  C.h. 

Zcntralblatt   fiir   Gynakologic        ...  ...  /bl.    f.   (iyn. 

Zentralbbitt  fiir  klinischc   (innerc)   Mcdi- 

zin /Id.    f.  kl.  M. 

Zcntralblatt  fiir   LnryiigoloKie       ...  ...  /Id.    f.    \.. 

Zentralbbitt    fiir    die    mrdizinischcn   Wis- 

senschaft(Mi  ...         ...         ...         ...  /bl.  f.  iii.   W . 


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l)K  J()i\'(i.      I).    I'astcuris.    d.    jVlil<ii    u.    d.    Abtoi.    v.    'I  h.   liz.    N.    T.    v.    Gen., 

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INDEX. 


A. 


Al:)cl()niin;i  1    |),iins,  208 

—  tuberculosis,  loy 
Abortion,  158 
Abscess,  acute,  417 
— ,  bone,  212 

— ,  brain,  197 

— ,  cold,  178,  211 

— ,  joint,  212 

— ,  otitis  media,  406 

— ,  retropharyngeal,    197 

— ,  skin,  184 

— ,  wandering,  178,  211 

Acneiform  tuberculosis,  igo 

Acne  pustules,  282 

— ,  scrofulous,   188 

—  varioliformis,    182 
Acnitis,  i8g 
Acrimonia  acris,  48 

—  scrophulosa,  6 
Act  of  defence,  230 
Adenoid  vegetations,  12 

,  diagnosis  of,   194 

,  symptoms,  195 

,  therapy,  399 

Age,   dilTerence  in,  3,   149 
— ,  influence  on  prognosis,  229 
Agglutination  test,  249 
Air  baths,  329 

—  in  prophylaxis,   280,  327 
Albuminuria,  213 

— ,  orthostatic,  214 
Alcohol,  294 
Alcoholism,    149 
Allergie,  258 

—  according  to  age,  259 

—  in  chorea,  258 

croupous,  pneumonia,  258 

epilepsy,  258 

herpes,  258 

hysteria,  258 

■  joint  rheumatism,  258 


Allergic  in  measles,  257 

pleurisy,  258 

purpura,  258 

scarlet  fever,  258 

scrofulosis,  264 

syphilis,  258 

typhus,  258 

— ,  modification  of,  254 

— ,  negative,  257 

— ,  prognosis,   251 

— ,  proof  of,  251 

— ,  reaction,  250 

— ,  results,  257 

Amylaceous  diathesis,   50 

—  nourishment,  292 
Amyloid  anaemia,  213,  237 

—  degeneration,  214,  216,  225 
Anchylosis,  212 

Angina,  195 
Antibodies,  250 
Antiformin,  247 
Aphonia,  205 

—  diagnosis,  238 
Arsenic,  375 
Arsenical  springs,  339 
Aspergillus  in  the  ear,  igS 
Asthma,  206 

Atropin,  208 

Auricle,  eczema  of,  198 

Auscultation,  240 

—  of  joints,  243 
Avian  type,  120 


B. 


Bacon,  friction  with,  387 

Bacterial  toxins,   160 

Bathing-places,  346 

— ,  alkaline  springs,  347 

— ,  arsenical,  340,  347 

— ,  carbonic  acid,  341,  347 

— ,  iodine   drinking  waters,   341-347 

— ,  iron,  341,  347 


32 


49S 


INDEX 


Bathing-places,  sea,  337 
— ,  sulphur,  330 
Baths,  331 
— ,  effect   of   mineral,  331 

sea,  Z3,7 

— ,  indication  for  mineral,  2>2>3 
sea,  33S 

—  in  prophylaxis,  281 
— ,  mineral,  331 

— ,  mode  of  use  of  mineral,  334 

sea,  338 

— ,  number  of  mineral,  336 

sea,  339 

— ,  sun,  342 

Benignity,  cause  of,  229 

Bleeding,  207 

Blenorrhoca,    199 

Blepharitis,  199 

Bloch's  squeezing  method,  249 

Blood,  changes  in,  213 

—  corpuscles,  213 
Bocck's  sarkoid,   iqo 

Bone  measurement  of  temperature,  244 
— ,  pains  in,  209 

—  scrofulosis,   209 

—  symptoms,  200 

—  thickening,   209 

Bone  and  joint  affections,  209 

diagnosis,    243 

auscultation,  243 

,  fungous  affections  of,    10 

infection,    170 

localization,      frequency      of, 

133 

—  —  —  morbid  anatomy,  175,   177 
oedema,  243 

,  Rontgen  rays  and,  243 

—  —  —    scrofulosis,   175 

•  —    tuberculosis,    177 

Bottle   feeding,  285 
Bovine  bacilli,  104 

,  difference  from  human,  265 

,  identity  of,   232 

,  lessened  pathogenicity,  117 

,  skin  infection  by,  116 

,  virulence   of,    112 

—  infection,   107 
by  milk,    1 1 1 

,  extent,  greatness,  danger,  107 

__  —  in   lungs  and   bronchial   glands, 
116 

scrofulosis,  41 

•  youth,  41 


Bovine  infection,  morbid  anatomy,  178 

—  type,  Z7,  104 

,  importance  in  childhood,  45 

,  scrofulosis,  45 

in  lupus,  43 

tuberculosis     of     bones     and 

joints,  42 
,  inoculation  experiments,  100 

—  ■ — ,  its  consequences,  46 
Breast,  tuberculosis  of,  87 
Bronchial  glands,  203 
,  infection  of,  122 

,  measurement  of  temperature  in, 

238 

—  - — ,  rupture  of,  203 

,  symptoms,  204 

— ,  cough,  240 

,  tuberculosis  of,  67,  83,  94,  240 

— — ,  frequency  of,    133 

,  diagnosis,  239-244 

Bronchitis,  55 
Bronchophony,  240 


C. 


Cachexia  scrophulosa,  7 

Calot  corset,  416 

Carbonic  acid,  artificial,  333,  369 

baths,  342 

Caries,  peripheral,   178 

— ,  sicca,   177 

— ,  teeth,  87 

Catarrh,  201 

— ,  bronchial,  &c.,  diagnosis,  238 

— ,  laryngeal,   238 

Children,  care  of,  279 

— ,  foods  for,  291 

— ,  health  resorts  for,  343 

— ,  hospitals  for,  351 

—    in  spas,  351 

— ,  mortality  of,   311 

— ,  places  for,  308 

— ,  treatment     of,     summary,     363-366 

— ,  watering    and    sea-bathing    places 

for,   346 
Cinnamic  acid,   385 
Cleanliness,  280 
Climate,   167 
Clothing,  300 
Cod-liver  oil,  324 

,  substitutes  for,  325 

Cold  in  the  head,  193 
Conception  of  scrofulosis,  14 


INDEX 


499 


Conjunctival  reaction,  255 

,  contra-indiration  to,  256 

Conjunctivitis,  256 

—  ,  treatment,  409 
Contagiousness,    146 
Contrccoup,  171 
Cornea,  affections  ot,  410 
Corpora  oryzoidca,    iy<) 
Corset  calot,  416 

— ,  gelatine,  416 

Coryza,  tubercle  bacilli  in,  13 

Course  of  scrofulosis,  21Q 

Coxitis,  210 

Creches,   305 

Creosote  and  its  derivatives,  3j() 

Cretinism,   i6(j 

Cure,  open-air,  327 

Cutaneous  test,  46,  251 

—  reaction,   18,  251 
Cyanosis,  206,  241 

D. 

Day  settlements,  349 
Deafness  and  dumbness,  1Q7 
Demineralization  theory,   52 
Dentition  eczema,  183 

,  source  of  infection,    142 

Diagnosis,  clinical,  233 
— ,  bacteriological,  245 
— ;  differential,  244 
— ,  tuberculin,  250 
Diarrhoea,   214,   291 
Diathesis,  8 

—  and  carbohydrates,  50 
— ,  eosinophilia,  53 

— ,   exudative,  49 

— ,  inflammatory,  49 

— ,  lack  of  albumin,  50 

— ,  localized,  60 

— ,  lymphatic,  48 

— ,  scrofulous,  8,  74 

— ,  tuberculous,  8,  59 

Diet,  rules  of,  323 

Digestion,  disturbance  of,  214 

Dioradin,   412 

Diphtheria,  196 

Disease,  readiness  for,  55 

Diseases  of  rabbits,  272 

Double  infection,  35,  96 

Dwelling-houses,    163,   304 

— ,  laws,  281,  30S 

— ,  nurseries,    282 

— ,  prophylaxis,  2 So 


Dyscrasia  acris,  48 
l^yspcpsia,  scrofulous,  2/4 
Dysijhagia,  205 
DyspnoM,  2()f) 

E. 

Ear  eczema,  38 

—  -    ,  exi)erimf;ntal  infection,  80 

infection,   clinical  observations, 

87 

,   localization,  frequency,   13G 

,  symptoms,  196 

-—     -,  therapy,  305 
Ecthyma,  scrofulous,  182 
I'-ctropion,  200 
l':czema,   53 
— ,   diagnosis  of,  236 
-",  diet  in,  392 

—  pustulosum,  &c.,  182 

—  scrofulosorum,    189 
Eggs,    166 
Embryonaiism,  71 
Empyema  artic.  tub.,  179 
Endogenous  factor,  17,  41,  47,  60,  6q 
Eosinophilia,  213 

Erethistic  habitus,  216 
Erysipelas,    169 
Erythema  induratum,    187 

—  nodosum,  38 

—  perstans,   188 
Etiology,  5 

Eustace  Smith  phenomenon,  241 
Exanthemata,   168 
Excoriations,  281 
Exogenous  factor,   15 

—  — ,  different   virulence,    17 

,  evils  of,  21 

Experiments  on  animals,  33 

,  sources  of  error,  34 

Exudative  diathesis,  49 

Eye  infection,  86 

,  symptoms,    199 

,  therapy,    409 

Eyelids,  410 

— ,  eczema  of,  391 

— -,  reaction,  255 

— ,  tuberculosis  of,  frequency  of,  144 

F. 

Facial  paresis,   198 
Facies   scrofulosa,    183 
Feeding-bottle,  285 
Feeding,    over-,    49,    295 


5O0 


INDEX 


Feeding,  under-,  51,  295 
Fever,  215 
— ,  hectic,  212 
Fistula,  bone,  212 
— ,  neck  glands,   203 
Fluor  albus,  201 
Foci,  latent,  1 16 
Folliculitis,    186    ■ 
— ,  acneiform,   190 

—  scrofulosorum,   187 
Food,  mixed,  293 

Forest  recreation  jjlaccs,  304,  325 

,  feeding  in,  307 

,  list  of,  307 

—  schools,  319,  327 
P^rame,  protective,   283 
Friction  with  bacon,  387 

soft  soaj),  385 

Fungus,  175 

—  joint,  211 


C. 


General  health,  225 
Genesis  of  scrofulosis,  75 
Gibbus,  213 

Glands,   extirpation,  413 
— ,  localization  of,   132 
— ,  morbid  anatomy  of,   174 
— ,  part  played  by,  127 
— ,  prescapular,    117,  231 
-—  — ,  diagnosis  of,  237 
— ,  streptococci  in,  23 

,  symptoms,  202 

,  therapy,  203 

— ,  topography  of,    128 

— ,  tubercle  bacilli  in,  9,  10 

Gomme  scrofuleuse,   184 

Graduating-house,  340 

Granules,  Much's,  247 

Guaiacol  and  its  derivatives",  368 

Gymnastics  in  prophylaxis,  314 

H. 

Habitus,  crethisiic,  216 
—  (scrofulous),    torpid,    216 
Hsemoglobin  content,   214 
Haemoptysis,  207 
Hair,  tufts  of,  54 
Hairiness,   54 
Handkerchief  using,  281 
Hardening,  299 
Health   resorts,  329 


Health  resorts,  choice  of,  343 

,  climatic,  329 

,  mountain,  344 

,  sea,  348 

,  summary  of,  344 

Heart,  derangements  of,  204 

— ,  hypertrophy  of,  205 

HercdiUuy  afTcctions  (statistics),  155 

Heredity,  149 

— ,  diagnosis,  237 

— ,  disposition    to,    149,    161 

— ,  germinativc,   150 

—  of  pyogenic  scrofulosis,  149 
— ,  placental,  153 
Hip-joint,  tuberculosis  of,  416 
Historical  survey,  5 
Hoarseness,   205 

— ,  diagnosis,  238 
Holiday  camps,  349 
Hordeolum,  410 
Hospitals  for  children,  351 
Human    bacilli,     difl'ercntiation     from 
bovine,  265 

,  identity  of,  232 

Hydrops,  tuberculous,  212 
Hygiene  in  cowsheds,  286 
Hyperplasia,  fibrous,   174 
— ,  lymphatic,  48 

—  of  pharynx,  240 
Hypophosphitcs,  325 


I. 


Identity     of     scrofulosis     and     tuber- 
culosis, 7,   16,  18,  57 
Impetigo  contagiosa,  233 

,  diagnosis,   234 

,  therapy,   282 

Infantilism,  71 

Infants,  care  of,  279 

— ,  tuberculosis  of,  prevention  of,  285 

Infection  and  exudative  diathesis,  55 

— ,  avoidance  of,  300 

— ,  bovine,  46,  105 

—    by  inhalation,  83 

injection,  79 

milk  and  its  products,  105 

•    tuberculous  meat,   tZ'i  105 

causative   agents,  75 

clinical  experience,  85 

cutaneous,  80 

dirt,  75,  165 

dissemination  of,   122 


INDEX 


501 


Infection,  (effects,   cliffcn-ni ,    117 

—  experiments,  f;nilis   in,    100 
— ,  human,  163 

—  in  animals,  79 

mucous  membranes,  (Si 

the  family,  300 

— ,  influence,  of   dilTcrcnt  fiulois,   117 

— ,  intestinal  canal,  83 

— ,  intraperitoneal,  84 

— J  intravascular,  iS5 

— ,  lung  inhalation,    100 

— ,  means  of,   in  ni;in,   ']'] 

— ,  mixed,  177 

— ,  mode  of,  76 

—  of    glands     from     tributarj'-     area, 
117,   130 

organs  of  respiration,  S3 

— ,  opportunities  for  diagnosis,  3,  235 

— ,  parallel  and  retrograde,    120 

— ,  pyogenous,  75 

— ,  scrofulous,   74 

— ,  spontaneous,  -^z^  35 

— ,  subcutaneous,  70 

— ,  tendency  to,   76 

Infectious  diseases,   opportunities  for, 
i6g 

Infectiousness  of  scrofulosis,   146 

Influenza,  197 

Inguinal  glands  symptoms,  203 

Inheritance  of  scrofulosis,  150 

tuberculosis,    154 

Instinct,   218 

Instruction,  303 

Intertrigo,    181,  280 

— ,  therapy,  280 

Intestinal  canal,  experiments,  83 

—  glands,   tuberculosis  of,  qo 

—  infection,   109 

,  clinical   experience,    1 1 1 

,  diflficulty  of,    113 

,  experimental,    114 

Intradermic   reaction,  254 

Iodine,  36 

Iron  carbonate,  372 

—  mineral  waters,  331,  337 

—  permanganate,  373 

—  preparations,  372 


Joint  tuberculosis,    151 

—  and  bone  aifections,  fungous,  170 

,  infection,  169 


Joint  and  bone  ailf^Mion-,  moil^id  aii.i- 
tomy,  17s,  179 

,  possibility  of  healing,  229 

,  scrofulosis,  406 

,  symptoms,  210 

,  tubercle  bacilli  in,  q 

K. 

Kefir,  323 
Keratitis,  400 
Kindergartens,  305 
Kissing,  139,  301 
Kitchens,  people's,  303 
Koch's  experiments,  9 
Koumiss,  323 

L. 

Laryngeal   catarrh,  238 

—  spasm,  205 

Latency  as  objection  to  law  of  locali- 
zation, 97 

Latent  foci,   BarteFs,  97 

Law  of  localization,  88 

,  experimental  errors,  100 

,  morbid  anatomy,  experience, 

109 

-,  objections,  89 

Lecithin,   326 

Leucocytes,  53 

Lichen  nitidus,    190 

—  sci"ofulosorum,  185 

,  tubercle  bacilli  in,   186 

—  urticatus,  391 
Ligroin,  246 
Linen,  under,  282 
Lipanin,  323 

Lips,  infection  by,   139 

Lungs,  infection  of,  by  bovine  bacilli, 

114 

inhalation,  go 

,  intestinal  origin,  92 

— ,  primary      tuberculosis      of,     from 

cervical  gland  tuberculosis,  102 
Lupus,  68 
— ,  diagnosis,  1S3 

—  exulcerans,   185 

—  foUicularis  disseminatus,  188 
faciei,  188 

— ,  frequency  and  localization,  137 

—  miliaris,   188 

—  pernio,  189 

—  serpiginosus,   183 
— ,  symptoms,   183 
— ,  therapy,  393 


502 


INDEX 


Lupus  tumidus,  183 
Lymph  current,  74 

—  system,  215 

—  vessels,  permeability  of,   70 

,  tuberculosis  of,  70 

Lymphocytes,  213 
Lymphoid  tubercle,  98 
Lymphoma,  leucaemic,  244 

— ,  pseudo-leuc?emic,  244 
— ,  scrofulous,  244 
Lysin,  252 

M. 

Malt  extract,  preparations  of,  324 
Mapped  tongue,  54,  56,  181 
Meals  for  children's  food,  292 
Measles,  69,  168,  186,  197,  237,  301 
Meat  preparations,  293 
— ,  tuberculous,  107 
Mediastinal  cough,  240 

—  glands,  239 

—  - — ,  diagnosis  of,   240 
Mesenteric  glands,  scrofulosis  of,  244 

,  diagnosis  of,  244 

,  symptoms,  207 

in  scrofulosis,  207 

,  tuberculosis  of,  68,  96,  104 

Middle-ear  inflammation  and  catarrh, 

197 

Miliary  tuberculosis,   170,  213 

Milk,  additions  to,  for  preserving,  289 

— ,  artificial  preparation  of,  291 

— ,  changes  in,   296 

— ,  consumption  of,    105 

— •  ■ ,  dangers  of,    105 

— ,  cow's,  nourishment  by,  285 

— ,  human,   nourishment  by,  284 

Milking,  aseptic  methods  of,  287 

Mineral  baths,  323 

Miscarriage  (see  Abortion) 

Mixed  infection,  31,  81,  177,  225 

Morbid  anatomy,   109,   173 

Mortality  statistics,  276 

Mother  lye,  335 

Mouth,  localization  and  frequency  of 
scrofulosis  in,   140 

Mouth  and  pharynx  infection,  clinical 
observations,  86 

Much's  granules,  247 

Mucous  membrane  anatomical  varia- 
tions, 66 

,  diseases  of,   193 


Mucous  membrane,  experimental  in- 
jection of,  81 

,  individual  ditTerenccs,  72 

,  penetrability  of,  62 

,  according   to   age,  66 

sex,  71 

,  scrofulous  tendency,   61 

,  therapy,  399 

,  tuberculous  affections,  138 

Muscle  atrophy,  210 

N. 

Naegeli's  foci,  1 17 

Nasal  mucous  membrane,  hyper- 
trophy of,   193 

,  symptoms,    193 

Nasopharyngeal  catarrh,   401 

Neck  glands,  infection  of,   123 

,  point  of  entry,    102 

,  tuberculosis  of,  67 

,  symptoms,   202 

,  transition    to    pulmonary 

tuberculosis,    102 

Nervous  system,  215 

Neuropathy,  52 

Night  camps,  307 

Nose,  affections  of,  400 

—  bleeding,  205 

— ,  infection   of,  clinical   observations, 

87 
— ,   localization   frequency,    138 
— ,  local  symptoms,    193 
Nourishment,    166,  283,  296 

—  by  bottle,  285 

cows'  milk,  285 

eggs,   166 

—  in  childhood    291 

mother's  milk,  166 

— ,  mixed  food  in,  283 

—  and  diathesis,  49 
— ,  faulty,  166,  296 
Nucleogen,  326 


(Edema,  205,  240 

CEsophagus   glands  bursting   through, 

206 
Ointment  reaction,   253 
Onanism,  166 
Oi)en-air  cure,  327 
Ophthalmic  reaction,  255 
Opsonin   determination,   249 
Orthopnoea,  205 


INDEX 


503 


Osteomyelitis,   178 

Ostitis,   177 

Otitis  externa,   hj8 

—  media,   197 
Otorrhona,   234 

— ,   tubercle  in,   12 
Over-nourishment,  50 
Ozaena,  195 
— ,  diagnosis  of,  236 
— ,  therapy,  282 
— ,  tubercle  in,   12 

P. 

Paleness  of  skin,  54 
Palpation  with  sound,  241 
Pannus  phlyctenulosus,  igg 
Paracentesis    of    membrana    tympani, 

406 
Parallel  infection,  q6 
Parapsoriasis  Brocqu,   igo 
Passage  through  animals,  34 
Pediculi,  281 
Percussion,  240 
— ,  bone,  210 
Periadenitis,  44 
Periostitis,    178 

—  mastoidea,  409 
Peritonitis,  243 
Permeabilit}^  of  skin,  64 

,  mucous  membranes,  66 

Persistency,    14 
Pharyngitis  sicca,  39 
Phenomenon,   Eustace   Smith,   242 
Phlyctense,    55,    igg,    200 
Phosphorus,   326 
Photophobia,  410 

Phthisis  mesenterica,,  208 

—  scrophulosa,    7 
Physical  examination,  239 
Phytin,  326 

Pirquet's  cutaneous  reaction,  251 
Pityriasis  rubra  hebrae,  189 
Placental  tuberculosis,  153 
Plaster-of-Paris  bed,  416 
Playgrounds,  315 
Points  of  entry,  237 
Poison,  bacterial,  199 
Post-mortem  tubercle,  69 
Pott's  curvature,  212 
Pregnancy,  167 
Prison  infection,   165 
Prognosis  according  to  age,  227 


Prognosis  according  to  v^m^I  position, 
149 

type  of  infection,  226 

Prophylaxis,  275,  302 
— ,  difficulty  of,  302 
— ,  instruction  in,  303 
Protective  frame,  283 
Protylin,  326 
Prurigo,  181 

Pseudo-heredity,   78,  159 
— ,  scrofulosis  and,  233 
Pulse  in  diagnosis,  205 
Pupils,  diagnosis,  239 
— ,  dilatation  of,  205 
Pus  cocci,  75 

,  appearance  of,  75 

,  virulence  of,  75 

Pyaemia,  197 

Pyogenic  form,  22,  219 

Pyogenous  bacteria,   17 

,  character  of,    19 

,  course,  29 

,  diagnosis  of,  233 

,  duration  of,  219 

R. 

Rabbits,  diseases  of,  272 

Radium  sulphate,  40 

Reaction,  conjunctival,  &c.  (see  Tests) 

— ,  Wassermann's,   265 

Readiness  for  disease,  55 

Respiratory  organs,  83 

,  infection  of,  83 

Retrograde  dispersal,  222 
Retropharyngeal  abscess,  197 
Rheumatism  in  children  (Comby),  54 
Rhinitis  atrophic,  194 
— ,  chronic  purulent,  193 
^,  scrofulous,  193 
— ,  therapy,  400 
Rhymes,  303 
Rontgen  rays,  241 

S. 

Salt  baths  at  home,  368 
Salts,  changes  in,  52 
Sapo  viridis,  385 
Sarcoid  (Boeck),  189 
Scalp,  cleanliness  of,  281 
School  baths,  317 

—  doctors,  319 

—  feeding,  31S 


504 


INDEX 


School,  forest,  319 

—  hygiene,  313 

—  overwork,  313 

—  playgrounds,   316 

—  prophylaxis,  313 
— ,  the  child  at,  313 
Scleroderma,   190 
Scrofula  fugax,  174,  220 
Scrofulides,  169 
Scrofuloderma,  11,   175,   184 

—  ulcerosum,  184 
Scrofulosis,  7 

— ,  conception  of,  6,   14 
— ,  prison,    165 
Scrofulous  acids,  6 
Sea  baths,  337 

,  effect  of,  32,7 

,  indication  for,  338 

,  mode  of  use,  338 

,  season  for,  339 

Seborrhoea  sicca,  54,  181 

—  — ,  treatment  of,  390 

Sex,  occurrence  according  to,  3 

Sheds,  Docker's,  306 

Ship  sanatoria,  331 

Skin  abscesses,  184 

— ,  a  protective  organ,  61 

— ,  affections  of,  388 

— ,  anatomical  differences,  64 

— ,  individual  differences,   71 

■ — ,  infection  by  bovine  barilli,    116 

— ,  permeability  of,  64 

— ,  tuberculides  of  the,  186 

—  tuberculosis,   81 

,  frequency  of,   142 

Small-pox,   168,   197 

Snake  poison,  reaction  to,  249 

Soft  soap,  385 

Soil,  167 

Soup,  296 

Spinalgesia,  239 

Spina  ventosa,   178,  209 

"  Splitter"  bacilli,   191 

Spondylitis,  210 

Spontaneous  infection,  11 

Staphylococci,    13,  23 

Status  lymphaticus,  264 

Streak  reaction,  254 

Streptococci,  23 

— ,  appearance,  75 

in  glands,  23 

Stridor,  206 
Strofulus,  53 


Struma,  5,  7,  169 
Stye,  410 
Subluxation,  21 1 
Suckling,  prize  for,  289 
Sun  as  prophylactic,  280 
Symptoms,  characteristic,  180 
Syphilis,    169,  245 

T. 

Tabes  mesenterica,  106,  208 
Teeth  caries,  87 

in  scrofulous  persons,   196 

,  sign  of  exudative  diathesis,  54 

,  sites  of  infection,    140 

Temperature,  238,  244 
Tendency,  the  scrofulous,  48 

,  anatomical   explanation,   61 

Test,  intradermic,  254 

— ,  Moro,  253 

— ,  ophthalmic,  255 

— ,  subcutaneous,  2C3 

— ,  v.  Pirquet,  251 

Therapeutics,  321 

— ,  general,  322 

— ,  local,  388 

— •,  medicinal,  370 

Thiocol,  369 

Tongue,  mapped,  54 

Tonsillar    tuberculosis,    103 

Tonsillectomy,  403 

Tonsillotomy,  402 

Tonsils  as  point  of  entry,  103 

— ,  treatment  of,  402 

Torpid  habitus,  216 

Town  and  country  life  influence  on 
disease,  305 

Toxic  tuberculosis,  59 

Tracheo-bronchbscopy,  241 

Tracheotomy,  207 

Trachoma,  201 

Tubercle  bacilli,  appearance  of,  30 

,  bovine  type,  43 

,  cultural  differences,  31 

,  demonstration  of,  245 

,  difference  in  virulence,  31 

J  differentiation    in    human    ar.d 

bovine  type,  265 

,  effect  of  different  stocks,  29 

. ,  etiological      differentiation      cf 

type,  47 

human,  occurrence,    77 

in  attenuated  sputum,  24 


INDEX 


505 


Tubercle    h.Killi,     m     boiK-    .-umI     jr,ii,t 

affections,  42 

in  m;in,   ij 

in    |)iiiiiiin,.ii  y    f  iiho  <  11  losis,    31; 

in     tiibcK  iilosis    of     mcsenterir; 

and  neck  glands,  41 

,  mode  of  Jnfcf;(ion,  -ji) 

J   number     influence     on     nalure 

and  course  of  infection,  24 

,  spread  in  the  body,  89 

transmission  in  l)lood,  (^5 

)  typus  avium,  120 

l^ovinus,  28 

humnnus,    28 

—  materi;il,  <S 

post-mortem,  6g 

Tuberculides,  i6q,  184 

— ,  bacilli  in,  iq2 

— ,  cutaneous  reaction,   185 

— ,  demonstration  of,  236 

— ,  origin  of,   iqo 

— ,  symptoms  of,  192 

— ,  treatment  of,  399 

Tuberculin,  378 

— ,  cutaneous  test,  251 

— ,  diagnosis,  250 

—  injection  in  cows,  286 
— ,  mode  of  use,  379 

—  ointment,  253 

—  plaster,  254 

—  test,  subcutaneous,  263 
Tuberculosis,  avian,  120 


I'uberculosis,    human   and    iy'<;,i.i,    27 
— ,  pustulo-ulc(5rcusc,  iqo 
— ,  scrofulosis,  course  of,  220 
—    verrucosa  cutis,  68 
Tumor  albiis,  179 

U. 

(Jnclcanlincss    favouring     scrofulosis, 

.05 
Under-feeding,   295 
Urticaria,    infantile,    182 

V. 

Vaccination,   169 
Vagina,  symptoms,  201 
Vegetable  diet,  298 
Verses,  mnemonic,  303 
Virulence  of  pus  bacilli,  22 

tubercle  bacilli,  23 

Viscosity  of  blood,  249 

W. 

Wandering  abscesses,  178 
Wassermann's  reaction,  284 
Wet  nurse,  284 
Whooping-cough,   168 


Y. 


Yogurth,  325 


INDEX  OF  AUTHORS. 


Other  Authors  may  be  found  in  the  Bibliography. 


A. 

Abraham,  140 
Abrami,  262 
Abramowski,  43 
Achard,  225 
Adam,  256 
Adamson,  160 
Aistermann,  2O4 
Albrecht,    11,    101,    110, 

125,  135,   145,  it)8 
Albrecht,  Eugen,    102 
Alexander,  13,  102,  114. 

187,     188,     189,     384. 

396,  398 
Allan,  205,  240,  243 
Amiet,  201 
Ammon,  v.,  280,  294 
Andeoud,  255 
Anders,   205 
Angerer,  v.,  413,  416 
Anschiitz,    143 
Appel,  188 
Aptekmant,  195 
Arloing,   11,  24,  31,  39, 

249,  257 
Arising,    P.,   83 
Armaingaud,    348,    354, 

3(i2,  366 
Armanni,   153 
Arndt,  188 
Arnold,  91 
Aronade,  253,   255,   25,  . 

382 
Arpad,  270 
Arth,  250 
Aschenheim,  52 
Aschoff,  gi,  152 
Askanazy,  179,  244 
Auche,   151 

Aufrecht,    103,    104,    126 
Avelino,  Martin,  371 
Avellis,  238 
Aviraguet,   69 
Axenfeld,  409 

B. 

Babes,  11,  80,  81 
Bach,  201 
Baecher,  249 


Baetzner,  417 
Baginsky,    49,    63,    109, 

137,      148,      168,     240, 

2O3,  315,  359 
Baldwin,    137,  255,  2O2, 

264,  265 
liallm,  92 
Jialmann,   133 
Jiandclicr,   141,  379,  384 
J^andeloque,  57 
iiandler,  252,  253 
Bang,   109,  290 
Barabaschi,  253 
]3arbe,  395 
Barbier,  256 
Barbieri,  258 
Barbuncanu,  258 
Bardach,   374,   375 
Bardenheucr,  343 
Barellai,  354 
Barety,   203,  206 
Barjon,  412 
Barlow,  288 
Barret,  242 
Barry,  207 
Barstow,  142 
Bartel,    54,    64,   83,   88, 

90,  91,  97,  98,  99,  "6, 

123,     126,     127,     129, 

168,    194 
Barthclcmy,    189 
Barthez,  8,  203,  205 
Bartholdi,  264 
Bartholdy,  263 
Bauer,     257,    259,     264. 

379,  380,  381 
Baumann,  25,  26,  34 
Baumes,  3,  6,   146,  218 
Baumgarten,  v.,  27,  28, 

30,  31,  63,  64,  83,  89, 

J51,   170,   175,   176 
liaup,  142 
liayewsky,  252 
Bavle,  7 
Bazin,  188 
Becher-Wolf,  305 
Beck,  207 
Beck,  J.,  262 
Becker,  203,  213 
Beckmann,   103,  142,400 
Beclere,  418 


Bchrend,    154 

Bchring,  v.,  31,  34,  4i, 
Oo,  04,  83,  90,  ]Oi, 
103,  ]05,  114,  124, 
159,  231,  249,  27s, 
288,     289,    290,    384 

Beitzke,  29,  31,  38,  40, 
91,  92,  99,  100,  lOI, 
102,  103,  104,  107, 
110,  121,  123,  125, 
15O,    270 

Belli,   77 

Bellmann,    188 

Belot,   412 

Benati,  214 

Benda,  69,  96,  no,  176, 
207,  266 

Bender,  77 

Bendix,   B.,  319 

Benecke,    152 

Beneke,  49,  33i,  332 

Bcneke,   Fr.,   359 

Benjamin,   53 

Benohr,  384 

Beraneck,   383 

Berend,  391 

Bergcr,  253,  260 

Bergeron,   354,  366 

licrggriin,  213 

Berghinz,   205 

Bergmann,  v.,  85,  88, 
134,  244,  245,  411, 
414,    415 

Bergonie,  412 

Bernard,    152 

Bernhard,  342 

licrnhardt,   246 

Bcrnhcim,  412 

Bernstein,    157,  396 

Bertarelli,   3''^5 

Bcrtcn,    86,    142 

Berthcraud,    154 

Berthold,   404 

Berti,   152 

Bertling,   288 

Berturclli,    170 

Beschorner,  257 

Besnier,  148,  184,  188, 
396 

Bey,  394 

Beyer,   413 


INDEX    OF    AUTHORS 


507 


Biedert,    105,    110,    134, 

148,  J  70,  2S4,  28H, 
291,  iH),  382,  386, 
389 

Bienstock,  61,  319 
Bier,  416,  418 
Biett,  390 
Biggs,   206 
Billroth,  49,  135,  145 
Binaghi,    151 
Bing,  256,  263 
Bion,   Pastor,   349 
Birch-Hirschfcld,  3,  49, 

149,  150,  152,  173, 
214,    216 

Birks,  52 

Bisanti,  03 

Bittrolir,   248 

Bjclilowski,  261 

Bjelilovvsky,    410 

Blaschko,  G5,  394 

Blitz,    iQS 

Bloch,  249,  250,  268 

Blum,  258,  263 

Blumcnfcld,  274 

Boas,   248 

Boas,  Harald,   11 

Bock,  64,  93,  384 

Bockhardt,  76,  Tj 

Boeck,  II,  236 

Boeck,     C,     185,      187, 

188,  189,    192 
Boeg,    157 
Bogolcpow,    189 
Bokac,  188 
Bolle,   286 

Bollinger,  25,  64,  77,  83 
Bonamy,   223 
Bondi,   254 
Bondy,    154 
Bongartz,  201 
Bongert,    102,    109,   151 
Bonome,  269 
Boral,   256 
Borriglione,  343 
Borsecky,   417 
Bougeron,    13 
Bouilly;  413 
Bourget,  258 
Boutellier,  342 
Bowlby,  417 
Boyd,   261 
Bradley,   413 
Brandeis,   264 
Brandenberg,  258 
Brandenstein,  255,  264 
Brandes,  417 
Braquehaye,  39 
Brauer,   339,  361 
Braun,  332,  341,  404 
Breeke,   242 
Brehmer,  28,  299 
Brem,   246 
Bresgen,  218,  400 
Breton,   93 
Bride,  142 
Brieger,  142 


I'rindcau,    152 

I'.nndcl,    142 

IJrion,    24fj 

Hroca,    142 

iir()(j(iu,    188,    190 

IJronscjn,    18O 

UroMssais,  7 

Hriickner,  262,  265 

Hnin,   v.,   22,  225 

Hruning,    134,  2O2,  2O4 

Hruning,   417 

Hruno,   200 

Hruusgaard,    189 

Jhuli,   256 

lUirhner,  "]■] 

Ikig.ijewski,    155 

iUiggc,    152 

Bullingcr,   254,   262 

liurach,  402 

Burchardt,    13 

Burckhardt,  29,  31,  32, 
34,  35,  36,  38,  42,  43, 
118,  156,  231,  264. 
268,  269,  270,  271,  272 

Burckhardt,  Hans,  266 

Bureau,   187,   188,   190 

Burg,   261 

Biirker,   330 

Burnet,     187,    201,    202, 

262,  263 
Busch,    282 
Jiuschkc,   254,   393 
Busing,   350 
Butler,  256 
Bylina,    262,   263 

C. 

Caan,  263 

Cacace,  ^^ 

Caccia,  412 

Cadier,   196 

Cahn,   103,   142,  274 

Galium,  Alac,  179 

Calmette,  gi,  92,  93, 
97,  159,  249,  256,  257, 
258,     259,     261,     262, 

263,  265 
Calot,  299,  417 
Calzolani,   261 
Camp,  de  la,  240 
Campana,   i88 
Cantani,  371,  384 
Carl,    152 
Carle,   188 
Carr,   134 
Caspari,  329 
Cassel,  371 
Castel,  du,  169 
Catoir,  263 
Cattle,    105 
Cavagnis,    151 
Caw,   43 

Cazin,  365,   366 
Cedercrentz,  391 
Chaldier,  214 
Chambrelent,   152 


Chantcmcssc,  258 
Chapotcau,  325 
Chajjut,  418 
Charier,   152 
Cliarlct,    258 
Charrin,    152 
("haurnicr,  234 
Chcron,  412 
Chevalier,  396 
Chcyne,    Watson,    134 
Chiari,  98,   1 10,  241 
Chlumsky,  262,  264 
('hreticn,  413 
Citron,  25O,  263,  26.<   26; 
Clark,   256 
Clarke,    274 
Clarus,  374 

Clemens,   189,  331,  zn 
Cobb,    105 
Cobbet,  91 
Cobliner,   52 
Cockel,    151 
Coderque,  261 
Cohn,  91,  188,  200,  256, 

258,    2/)3 
Cohnheim,  g,  88,  272 
Colas,  9 

Collin,  256,  261,  263 
Colling,  87 
Comba,  206 
Comby,    54,     159,     185, 

186,     246,     249,     256. 

261,     263,     264,     265. 

277,  290 
Cordua,  244 
Corner,  415 
Cornet,  G.,  39,  52,  63, 

70,  72,  83,  84,  88,  go, 

107,  115,  126,  151, 

153,  168,  272,  282, 

312 
Gornil,  10,  11,  142 
Correa,   418 
Cosco,  33 
Gouncilmann,    no 
Courmont,   64,    81,    152. 

249 
Cowie,   III,  152 
Cozzolino,    81,    82,    240. 

242,   249 
Cramm,  137 
Crokett,   403 
Crouzon,   151,   I5g 
Cruveilhier,   8 
Cullen,   5,  6 
Czerny,   44,    50,   51,    52, 

53,   54,  55,  56,  57,  64, 

161,      166,      181,     iQ=;. 

200,     2x8,     229,     230, 

231,     285,     292,     2Q5, 

296,     297,     298,     299. 

323,    372,    382 


Daels,   191, 
Dalton,  341 


508 


INDEX    OF    AUTHORS 


Damask,  256,  261 
Dammann,    34,    35,    39, 

270 
Daniclopulo,   256 
Daniels,  261,  375,  384 
Darier,    185,   187 
Dautwitz,  382 
Da  vies,   106 
Delarde,  92 
Delbanco,   188 
Delbet,   418 
Delrcz,   417 
Demme,   10,   11,   12,  86, 

148,     lOO,      184,     195, 

201,    412 
Denecke,  86 
Denig,  201 
Denke,  418 
Dent,  158 
Denys,  384 
Despres,  184 
Determann,    331 
Detrc,  274 
Dcutsch,   284 
Deutschlandcr,  418 
Deycke,  247 
Deygallieres,  8 
Dieterlen,  93 
Dina,    206 
Dionisio,    404 
Disse,  90 
Ditlevsen,  11 
Dittcosen,  248 
Dittrich,  207 
Dmochowski,    140,    142 
Dobisch,  41 1 
Dobroklonski,  83,  151 
Dobroklonsky,  64 
Doganoff,  252,  260,  264 
Dolaeus,   3 

Dold,  81,  8q,  246,  249 
Dolschenkow,  410 
Domenici,  412 
Dorner,    157 
Dorp,  D.  v.,  357,  418 
Dorset,  38,  270 
Dotti,   155 
Doutrelepont,      11,     86, 

142,     252,     391,     394, 

396 
Drasche,  326 
Dresch,   398 
Dresdner,  384 
Dreuw,  394 
Dubreniih,    187 
Duclaux,    13 
Dudley,   Tj 
Dufour,  256 
Diinges,  160 
Dupont,   256 
Diiqucsncl,  324 
Durand,   155 
Durig,   330 
During,   v.,   139 
Duval,  38 


Ebcr,  29,  Z2>,  35,  38,  40, 

loS,  2go 
Eckert,  239 
Edens,  44,  231 
Eflier,  307 
Ehrhardt,   143 
Ehrlich,  54,  379 
Ehrmann,    190 
Eiselsberg,  v.,  343 
Eisen,  256 
Eisenstcin,  410 
Elfer,  120 

EUermann,  247,  252 
Elsiisser,  M.,  262 
Elze,  213 

Emmerich,  260,  262 
Enderlen,  T] 
Engel,  0^,  ^2  57,  259,  2C4, 

379.,  380,  381 
English       Tuberculosis 

Commission,    35,    38, 

40,  41,  42,  43 
Ensch,  255,  300 
Entz,   257 

Eppenheim,  252,  256 
Eppinger,   54 
Epstein,    52,     154,    157, 

254,   382 
Erdely,    194,    241,    247, 

252,  255 
Erdely,    194,   241 
Erlandsen,  247,  252,  255 
Ernst,   270 
Escherich,    13,    15,    16, 

18,  21,  45,  51,  54,  56, 

57,  154,  162,  186,  201, 

217,     239,     240,     242, 

254,   339,  343,382,389 
Escomel,  140,   142 
d'Espine,  2,  240 
Etsches,   208 
Euler,  143 
Eve,    II,  24 
Eversbiisch,  391 
Ewald,   359,   372 
Ewich,   370 
Exner,  384 
Eyre,  255 

F. 

Fabian,    256,    258,    259, 

261,   263 
Fabrici,   247 
Fabry,  189 
Fairchild,  417 
Falk,  253,  255,  257,  4'7 
Falkcnheim,   244 
Fasano,  391,  401,  407 
Favre,  258 
Feer,  157,  242,  253,  256, 

257,     261,     262,     263, 

264,     283,     392 
Fehsenfeld,  261 


Feldman,    135 
Fenwick,  214 
Ferrand,  262,  412 
Ferre,   249 
Ferreri,   'i-j^    139, 
Fibiger,  29,  31,  32,  35, 

38,   39,   44,    III,    112, 

270 
Ficker,   64,  66,   67,    93, 

126 
Fife,  38 

Filipkiewicz,  262 
Findel,  26,  102,  114 
Finder,  403 
Finger,  188, 
Finkelstein,      52,     239, 

240,     242,     244,     246, 

296,  375,  392 
Finsen,  387,  390, 
Fisch,  R.,   105 
Fischer,  83,  loi,  142, 157 
Fliigge,  v.,  64,  114,  301 
Fontcs,  248 
Forsith,    274 
Fortineau,   284 
Foster,  417 
Fothergill,  378 
Fox,  Colcott,  188 
Francioni,  412 
Frank,  247 
Friinkol,  A.,  102,  319 
Frankel,  C,  25,  26,  3<i. 

81 
Frankenburger,  246 
Franzoni,   343 
Frcemann,   no 
French,  242 
Freudenthal,  103,  140 
Freund,     52,     54,     i6o» 

343,   397,   398,   418 
Frey,  385,  411 
Friedberger,    102 
Fried jung,  54 
Friedlandcr,  8,  391,  39(> 
Friedmann,     103,     140, 

141,   153,  371 
Friedrich,   172 
Frisca,  81 
Frobelius,   134 
Fromm,  208 
Fronz,  207 
Frosch,   91 
Fuchs,   381 
Fuchs-Wolfring,    248 
Fiirst,  M.,  320,   391 

C. 

GafFky,  91,   168 
Galbo,  90,   153 
Gallaverdin,    112 
Galtier,   153 
Galtier,    153 
Ganghofner,      52,     105, 
III,  373,  382,  384 


INDKX    OF    AUIilORS 


y>9 


Gardiner,   v.,  412 
Garrc,  3,   77,  41O 
Garrod,  243 
Garlucr,   151,   153,  394 
Gastincl,   188 
Gaucher,    lyo 
Gebhardt,  25,   274 
Geil'rier,   237 
Gehcdini,    J03 
(Jcipel,    102,    152,  248 
Gcisler,  296,  392 
Geniari,  412 
GeiUes,    JS5 
Gen/.nicr,   41 1 
Gcorgi,   153 
Gcrber,   87,   236,  398 
Gerhardt,  240 
Gerlach,  77 
Gennonig,   258 
Gcrnzheim,   384 
Gcscheit,   249 
Glacssner,  384 
Glagc,    108 
Gnielin,  331 
Gnczda,    411 
Godfrey,   Rowland,    no 
Goebcl,    256,    257,    262, 

2C3,  264 
Gocpcl,  3SO 
Gocrdeler,   103,   140 
Goerlich,  256 
Goetsch,  379,  382 
Goggia,  31 
Goguel,   206 
Goldmann,  417 
Goldschmid,   102 
Goldschmidt,  328 
Goldstein,    155 
Goldzieher,  391 
Golis,  283 
Gomperz,   468 
Goodalc,  41,   140 
Goodlad,  8 
Goppcrt,   55 
Goring,   1 1 1 
Gbrres,  246 
Gorton,  109 
Gosselin,  27 
Gotsche,   252 
Gotschlich,   77 
Gottschalk,  396,  397 
Gottstein,   142,  403,  440 
Gougerot,    168 
Gourc,   142 
Gracoski,    249 
Gradcnigo,   142 
Graetz,   244 
Gram,  185,  247,  248 
Grancher,   153 
Graser,  86 
Gratias,  36 
Grawitz,    86,    87,     no, 

140,  142 
Graziani,   137 
Greco,  249 
Gregor,  292,  418 


(irJerriert,    2O2 
(irober,   103,  205,  239 
Grossc,    I  I  I 
( irossi:! ,    I  I'j 
('ii'i)\  li;i  11,  ;;';,    i  jO 
(iriiner,  43,  258 
Griiiibcrg,  371 
Grun(;r,   255 
Griinwald,   400 
(jryscz,   91 

(iii('n(;ui  (le  Mussy,  203 
Gunther,  256,  261 
Gucrin,  91,  92,  93 
Guinon,  205 
Gulliver,  206 
Gundobin,  213 
Guttmann,  72 
Guye,  194,  218 

H. 

Haab,   86,    144 
Haan,  de,  92,  120 
Haberlin,  331,  338,  364, 

365,  368 
Ilahn,   136,  397 
Haike,  139,  222 
Haiek,    194,    196 
Hail,   246 
Halle,    189 
Haller,  411 
Hallopeau,      170,      186, 

187,  189,  396 
Hamburger,     loi,     145, 

IS3,      187,     231,     236, 

254,   258 
Hamilton,  87 
Hamm,  152 
Hanot,  207 
Hans,  264 

Hansemann  v.,  no,  in 
Happe,   169 
Harbitz,   96,    124,    168 
Hart,  104,  160 
Harttung,   188 
Hartzell,  39 
Haserodt,  246 
Haug,  87,  406 
Hauser,   417 
Haushalter,    i6g,    186 
Haussmann,  386 
Hay,  277 
Hayashi,   200 
Hayes,   412 
Hazen,  159 
Hebra,   394.   399 
Hebreard,  8 
Heclit,    243,    369,    400, 

408,  411 
Hecker,   134,  242,  243 
Heim,  52,  258,  274 
Heinemann.  262 
Heinersdorff,  201 
Heisler,  241 
Heitz,   153 
Helferich,   393 
Hell,  257 


Heller,    iio,   ni,'  223 
I  I'irriliolz,  54,  249 
ll'hvi;.;,   331 
I  i'  rnsled,  384 
I  Icudelsolin,   140 
ii<'nig,  331 
Henkc,  152 
Ucnle,   125,  129 
Henoch,  3,  49,  144,  169, 

172,     182,     194,     208, 

216,     240,     370, 
H^rard,  205 
Hericourt,  293 
Hermann,  90 
Hertcl,  256 
Hertz,  255,  265 
Hcrxhcimer,  188 
Hcrzberg,  384 
Herzfeld,  2  46,  403 
Hess,  3O,   54,   108,    n2. 

249 
Ilfubner,     18,    20,     no, 

134,     217,     280,     298, 

332,  377,  380,  392 
Heuss,    28,    36,  37,    38, 

n5,   n7,  266,  2G7 
Heymann,  91,   106,  290. 

397 
Heyse,  69 
Hidaka,  188 
Hildebrandt,  192 
Hilgermann,  89 
Hillenberg,  46,  165 
Hirschberg,  343 
Hiss,  49 
Hochsinger,     152,     242, 

296 
Hock,  377 
Hoefnagel,  39 
Hoelzinger,  36,  39 
Hoff-Hansen,   365,   366 
Hoffa,     384,     386,    387, 

416,  417 
Hoffmann,  v.,  392,  402, 

410 
Hoffmann,      129,      244, 

246,  247,  384 
Hofmann,   140,  391 
Hohlfeld,   289 
Hohmeier,    375,    384 
Hollander,  397,  398 
Holmboe,  384 
Hoist.  87 
Holtzke,  410 
Honl,  152 
Honsell,  172 
Hoorn,  van,  396 
Hopfenhausen,  363 
Hopkins,    140 
Hoppe,   87,  142,  143,  326 
Hormann,  262 
Hornemann,  90 
Horner,  384 
Hiibner,    188,  398 
Huellen,  v.,  384 
Hiils,    III 


510 


INDEX    OF    AUTHORS 


Hiine,   247 

Hueter,   61,   62,  70,    7;. 

211,  412,   413 
Hufeland,   5,  7,  48,   s-^ 

57,  214,  237,  302,  378 
Huht,    377 
Hunter,   110 
Huscmann,  386 
Hutchinson,    188 
Hutinel,   157,  231 
Hymans,  384 
Hvnitsch,    142 
Hyrtl,    73,    129 

I. 

Igersheimer,  200 
Ipsen,   111,   179 
Irimcscu.  274 
Iselin,  418 
Isnardi,   170 
Ivannovics,  250 
Ivens,    142 
Ito,   140,    141 >    142 


Jacinski-Rudis,  418 

Jackh,  150 

Jacksch,   54 

Jacobi,  87,  186,  394,308 

Jacobson,  198,  391,  4o5i 

407 
Jacques,  242 
Jadassohn,  39,  185,  '8^- 

188,    189,    191 
Jaffe,    135 
Jamieson,  200 
Jaquet,  153 
Jarisch,   189,  393,  394 
Jatta,  33 
Jeanselme,  396 
Jensen,   29,   31,    32,  35, 

38,    39,    44,    III,    112, 

270 
Jerusalem,  343 
Jessel,  142 
Jessen,  41 i 
Jezierski,    153 
Jochmann,      249,      381. 

382,  417 
Joergen,    11 i 
John,    274 
Johne,   39,   III 
Johnson,   i  57,  320 
Joncso,    120 
Jorn,  36 
Joseph,  254 
Josias,  203 
Josserand,   103,  242 
Juliusberg,    187 
Jung,    152 
Jungraann,   393,   308 

K. 

Kanitz,  260 
Kantorovvicz,  417 


Kanzlcr,  10,  16,  17,  164, 
1O5,  324,  332,  341,387 
Kaposi,  185,   180,  394 
Kappesser,  385,  380,  387 
Kapsammer,  250 
Karcwski,  418 
Karlinski,    12,    3S,    124, 

151 
Karo,  384 
Kasselmann,    105 
Kastner,  v.,  77 
Katzenstein,  243 
Kaufmann,     255,      261, 

2O2,  3O5,  384 
Kaufmann,  E.,   102 
Kaurin,   202 
Kayser,   139 
Keller,  332,  333,  369 
Keller,    A.,  288 
Kelynack,  320 
Kerle,   384 
Kerr,   276 
Kersten,  246 
Kidd,    207 
Kiefer,  333,  339 
Kicnbock,   397,  418 
Kiener,   9 
Kiessig,  287 
Kilian,  401 
Kinghorn,    249 
Kingsford,    140 
Kirchner,   244,   319,   30  > 
Kirchner,     Martin,     77, 

156 
Kitamura,  125 
Kitasato,    105 
Klapp,  416,  418 
Klar,  185 
Klein,    109 
Kleine,   39 
Klemenko,   64 
Klemperer,  30,  31,  274, 

325,  381 
Klieneberger,  256 
Klimenko,   90 
Klimmer,  287,  290 
Klingclhocflfer,   386 
Klingmiiller,    185,    186, 

391 

Kluge,    157 

Knopfclmacher,   260 

Knoll,   248 

Knopf,  256,  258,  259, 
261,  262 

Koch,  8,  9,  10,  17,  24. 
26,  27,  28,  29,  31,  33, 
36,  37,  87,  90,  no, 
III,  112,  206,  207, 
230,  249,  252,  266, 
267,  272,  273,  287, 
290 

Kockel,   152 

Kofler,  403 

Kohler,    242,    261,    304, 

384 
Kohn,   256 


Kohlisch,   249 
Kolaczek,   249 
Konig,   212,  418 
Konigstein,  236 
Korncr,  71,  73,  87,   142, 

143 
Kolb,    162,   392 
Koliath,   170 
KoUmann,   386 
Kopmann,  403 
Koster,  8,  177,  179 
Koranyi,  Fr.  v.,  240 
Kt)rczc\vski,  262,  263 
Korczynski,  262,  263 
Kormann,   386,   387 
Kortum,  5,  6,  8 
Koschier,    142 
Koslovv,  247 
Kossel,    28,   29,   31,   33, 

34,  35,  36,  37,  38,  100, 

108,     112,     117,     248. 

266.     267,     273, 
Kovacs,   90,   93,  94,  95, 

97,  99 
Krabler,  108 
Kraemer,  381 
Kramer,  240 
Kramsztyk,  392 
Kraus,   188,   189,  254 
Kraus,   Alfred,    189 
Krause,  10,  11,  257,  382 
Krause,  P.,  404,  412,  418 
Krauss,  258 
Kreibich,   188,  189,  252, 

253,  257,  264 
Kren,   187 
Krietz,  257 
Kristen,  157 
Krokiewicz,   258 
Kromaycr,  397,  398 
Krompecher,   43,   230 
Krone,  340 
Kroner,  384 
Krouchkoll,   412 
Kriickmann,  86,   140 
Kriigcr,    1 1,   77,  246 
Kruse,    120 
Kiihnau,  log 
Kiimmel,  397 
Kiirbitz,   152 
Kiittner,   126,  254 
Kuhlmann,   189 
Kuhn,   T09 
Kunz,   77 
Kuss,  91 ,  102,  1 14 
Kustcrmann,   77 
Kuthy,  335 
Kuznitzkv,    188 
Kyrlc,   188 

L. 

Laas,  383 
T.achmann,   142 
Lacke,   256 
Lacker,  404 


INDKX     (Jl-     AUTHORS 


I  I 


Laennec,  7,  8 
Laffert,  102,  114 
Lafitte,   256 
Laird,   241 
Lallemand,  378 
Laloucttc,  203 
Lainballc,     Jobcil      f\r, 

372 
Landcrer,  385 
Lang,   303 
Lang-Popper,  yj3 
Langc,  246,  400 
Langc,  do,  342,  300 
Langhans,   28 
Langstein,    52,    54,     55i 

2q6,   332,  340,   30-2 
Langworthy,  403 
Lannclonguc,   152 
Lantier,  2O0,  399,  4' 7 
Lanza,  213 
Lapardt,  265 
Lapcrsonnc,  256 
Lapschin,  263 
Laquer,  375 
Larre,  77 

Lassar,  388,  390,  391 
Latemer,  187,   188 
Latham,    i59i  354 
Latour,  290 
Latz,  307 
Laub,  249 
Laureati,  242 
Lavrand,  404 
Lazarus,  54 
Leber,  13,  23 
Lebert,  3,  72,   134,  137, 

150,     167,     215,     216, 

302,     374,     375,     378 
Lecky,  277 
Legrand,  378 
Lehmann,  88 
Lehmann,  E.,  332 
Lehmann,   F.,   151 
Lehmann,  L.,  332 
Leiner,  187,  188,  190 
Leistikow,   399,  484 
Leloir,    11,  39,  87,    116, 

137,     139,     I/O,     190, 

393,  394 
Lemaire,  259,  262 
Lemoine,  214 
Lemoire,  251 
Lenhartz,   263 
Lenk,  384 
Lennhoff,  305,  367 
Lenzmann,   143 
Leopold,  236 
Lepelletier,  8 
Lepinay,  Mac  de,  254 
Lepine,  Jean,  256 
Lereboullet,  231 
Lermoyez,  142 
Leroux,   124,  363,  366 
Lerrede,  187 
Leschke,  270 
Lesieur,  64,  80 


Lcssellicrh,  ;80 
Lesser,  394,  397 
Leszczynski,   18O 
Lctts(jm,  354 
l-ctullc,   1 1,  25O 
Levy,  263,  264,  265 
Levy,  Fr.,  256 
Lcwandowski,  80,  193 
Lewin,  142 
Lexer,    140 
Lichtenstein,  244 
I^iebc,  25 

Liebermeister,  248 
Lignieres,  253,  2O0 
Lindem;inn,  87 
Lindenstein,   109 
Lingelsheim,  v.,  23,  24 
Lipstein,  23,  77 
Litzncr,   396 
Livierato,    129 
Lobcnstine,  152 
Lobstein,  91 ,   102,   114 
Locher,  340 
Locb,  206 
Loflfler,   109,  246 
Lori,    196 

Loewenljerg,   188,   194 
Loewenstein,  120,  381 
Loewy,  331,  338 
Loewy,  A.,  329 
Loewy,  J.,  65 
Lohrer,  207 
Lohse,   368 
Lomini,    no 
Londe,  153 
Loomis,   168 
Lorenz,  246 
Lorenzo,  106 
Lossen,  252 
Louis,  215 
Low,  Warren,  418 
Lubarsch,  g6,    100,    loi, 

102,    103,    140 
Lublinski,   181 
Lucae,  403 
Ludwig,  375 
Liicke,   210 
Ludke,   214,   262,   381 
LugoL  7,  146,   149,  155, 

157,      158,      167,     215, 

370,     401,     402 
Lukasiewicz,  186 
Lundis,  206 
Lupowski,  221 
Lurie-Liidke,  261 
Lusenbcrger,  258 
Lustgarten,    394 
Luzzato,  142 
Lyle,   153 

M. 

Macfadyean,  83 
Machnoff,  76 
i\Lacleod,  187 
jNIahat,  412 


Main  in  I,   ^^^ 
Makie,  404 
Makowski,  2O2 
Malcolm,  109 
Malgat,  343 
Mallinkrfidt,  102 
Mallory,  1 10 
Malm  Strom,  jOi 
Manasse,   374 
Man f red i,  80,   129 
Mantoiix,  254,  259 
Maragliano,  31 
Marbeau,  305 
Marcuse,  304 
Marfan,  222,  302,  413 
Marmorek,  384 
Marshall,   265 
Martin,    12 
Martin  Avclino,  371 
Martin,    H.,    9 
Martinet,    187 
Martius,    Oi,     150,     15O, 

160 
Mazzoni,  G.,  394 
Med  in,  102 
MedowikofF,  262 
Megias,  261 
Meirowsky,  398 
Meisels,  274 
Meissen,  97 
Menard,  417 
Mende,  247 
Mendelsohn,     47,      109, 

135 
Mendelsson,  392 
Mendez,  290 
Menier,  404 
Menzel,   135 
Mering,  v.,  323,  371 
Messa,  185 
Metschnikoff,   129 
Mever,  A.,   105 
Meyer,  J.,  81 
Meyer,  Karl,  54 
Meyer,    L.    F.,    52,    54, 

236,    296 
]\Ieyerhoff,  207 
]Meynet,  206 
^lichael,  207 
Alichalowicz,  240,  242 
Michel,  201 
Micheli,  256 
Michelsohn,  190 
Middeldorff,  145 
]\Iietzsch,   40 
Miglio,  249 
Mikulicz,  402 
IMiller,  155,  418 
^linkowsici,  381 
Mirauer,  252 
Mironescu,  gi 
Moberg,  398 
Mohler,  270 
]\roeller,  274,  288 
Moller,    142,    2^2.    261, 

381 


12 


INDEX    OF    AUTHORS 


jNlollers,  40,  286 

Mohler,  38,  40 

Mol,  3(^5 

Moll,  331 

Moniose,  248 

Monaco,  152 

Alongour,  155,  156,  264 

Monier,  293 

Monod,  .384 

Monsarrat,  112 

Montgomcrj'',  qi,  102 

Monti,  3,  50,  62,  133, 
213,  254,  260,  264, 
293,  343,  349,  361, 
352,     365,     366,     377 

Moorehead,    143 

Moos,    198 

Morawitz,  330 

Mordhorst,  165 

Morelli,  261 

Morin,  343 

Moro,  18,  19,  20,  21,  44, 
53,  56,  57,  58,  59,  63, 
154,  162,  185,  186, 
196,  229,  252,  253, 
254,  255,  260,  264, 
343,    392 

Morse,  400 

Morton,  277 

Mosetig-Moorhof,  394 

Mosse,  375 

Most,  70,  loi,  102,  103, 
104,     124,     126,     136, 

144,    413 
Moulinier,  257 
Moussu,  254 
Much,     185,     187,     189, 

247,  248,  413 
Muck,  407 
Muller,  E.,  296 
Muller,  O.,  239,  242 
Muller,  10,  39,  134,  189, 

244,    249,    329,    400 
Miinch,  246 

Miisscmeier,  34,  39,  270 
Murphy,  416 
Murray,  87 

N. 

Nadoleczny,  195,  402 
Nacgeli,   117,  119 
Naegeli-Ackerblom,  253, 

257,  260 
Nagel,  204,  240,  242 
Nakarai,  150 
Natwig,  331 
Nebelthaus,  64,  83 
Negrier,  378 
Neisser,    23,     77,      i75-. 

184,     186,     187,     188, 

239,     241,     394,     307, 

398 
Ncnninger,  126 
Nestor,  258 
Nettelbrock,  402 


Xeubaucr,  332 
Neudecker,  300 
Xeufcld,  290 
Ncukirch,    137 
Neumann,  4,  15,  16,  17, 

18,  91,    126,    190,   196, 

200,     204,     207,     223, 

235,    241,    296 
Neumann,  H.,  214 
Neumann,  J.,  381 
Ncumayr,   143 
Neureuther,  240 
Niche,  39 
Nicolaus,   258 
Nicdcrstein,  398 
Nikolski,   155 
Nitschc,  246 
Nobecourt,  142,  195 
Nobl,  186 
Nocard,    153 
Nocggerath,     242,     240. 

264 
Noetzcl,   128 
Noncwitsh,   108 
Noordcn,  v.,  293 
Nothmann,  52,  259 
Nouri,  80 
Novak,  152 
Nowack,  67 

0. 

Oberlin,  305 
Obcrwarth,  93 
Odcnthal,  87,   142 
Oehlecker,    26,    28,    31, 

34,  36,  37,  38,  41,  42. 

43,  45,  47,  94,  95,  98. 

100,     103,      123,      139, 

266,     268,     270,     271, 

272,    273 
Oekonomides,  207 
Oliari,    155 
Ollivier,  11 1 
Opificius,   188,    189 
Oppcnheim,     2^7,     264. 

319 
Oppcrt,  222 
Oronsby,  187 
Orth,  28,  64,  90,  93,  07. 

140 
Oitiz,  412 
Ostermann,      109,      114, 

137,     165 
Ostertag,  109,  290 
Ott,  S3 

Overland,   106 
Owen,  305 

P. 

Paganclli,  249 
Pagano,  342 
Pagenstecher,  A.,  11 
Paltauf,  54,  69 
Panisset,  93 


Paiisini,  120 

Pariente,    159 

Parker,  261 

Parodi,  38 

Partsch,   143 

Parturier,  251 

Passet,  91 

Paul,    126 

Pavli,  418 

Payc,  398 

Pawlowski,   11 

Pcarcc,   no 

Pegurier,  158 

Pel,  382 

Pcllizari,   186 

Pcntzoldt,  416 

Pernice,  150 

Pcrnossi,  L.,  342 

Pcrrochaud,  354 

Petersen,  207,  252 

Petit,  384 

Petri,    28,   77 

Petruschky,  239,  381 

Pfahler,  412 

Pfannenstiel,  396 

Pfaundler,  49,  51,  54, 
55,  56,  185,  242,  252, 
256,     264,     298,     400 

Pfeiflfer,  loi,  257 

Pfeiffer,  A.,  11 

Pfeiffor,  L.,  39 

Pforringer,  398 

Phili]),   293,   382 

Philippson,  187,  398 

Pick,  189,  191,  253,  380, 
391 

Pierry,   242 

Piesen,   253 

Piettrc,  159 

Piffl,     T42 

Pilip,   414 

l^illiet,   142 

Pins,    194,   234 

Piorry,   7,  240 

Pircra,    140 

Pirquet,  v.,  113,  185, 
200,  250,  251,  252, 
253,  255,  257,  258, 
260,  261,  262,  264, 
.265,     381,     382,     384 

Pizzini,   168 

Plantenga,    243,   288 

Plate,    89,   90,   418 

Plehn,    256 

Pluder,    142 

Polak,   206,   207,  384 

Poland,    206 

Pnliakov,    142 

Politzer,  '408 

Pollari,   257 

Pollak,  241 

Pnlland,    188,    189,   207, 

2^6 

Pollitzcr.    187 
Poncet,  86,  214 
Ponfick,  49,  62,  161 


INDEX    Ol'     A(/m(>l<S 


5'3 


Pons  y  Marqucz,  261 
Ponlini,    Dc,   324 
Portal,  7 
Postnikow,   384 
Potcn,   2O2 

Pottcngcr,   124,  384,  41' 
Poulct,  9,  413 
Prausnitz,    78 
Pregcl,   144 
Preisich,     50,    62,     i37i 

I3Q,  162,  165,  258 
Prclcitncr,   384 
Prcvost,    378 
Prcyss,    26 
Price-Jones,    1 1 1 
Pricsler,    116 
Prochaska,  365,  366 
Progulski,    274 
Prondfort,   F.,   395 
Purjesz,   257,   261 


Quadronc,   412 
Quaglio,   333 
Quain,  203 
Quenu,   418 


Rabben,   50 
Rabinowitsch,       Lydia, 

2Q,  "31,  34,  35,  38,  30. 

90,    93,    97,    120,    128. 

270 
Rabl,  3,  4,  72,  133,  172. 

41s,  416 
Rabow,   377 
Raissonier,  293 
Ramond,  225 
Ranazugi,  404 
Ranzel,   152 
Rappin,  284 
Rau,   50 

Rautenberg,  207 
Ravaut,   188 
Ravenel,  38,  39,  93 
Raw,  43,    106 
Raw,  N.,  33,  384 
Raydt,  333 
Recklinghausen,  223 
Reiche,   156,    157 
Reichel,  93 
Reichelt,  373 
Reichenbach,      26,      93. 

102,    114,    115 
Reichenbach,  H.,  64 
Reid,    106 
Raines,    190 
Reitmann,    188 
Rembold,    77 
Remlinger,   gi 
Renard,    417 
Rene   Quinton,    342 
Renon,  418 
Renouard,  393 
Rentzler,  274 

33 


Rcnzi,    dc,    244 

Rethi,    142 

Kcuncrt,    188,  206 

Rcuschcl,  254,  2O4 

Rcvillout,    19O 

kcyhcr,    214 

Rhazcus,   50 

Rhein,  201 

Ribas,   249 

Ribbcrt,     77,     96,      102. 

no,  188 
Richelot,   412 
Rirh(;t,   293 
Kichter,    385 
Richl,   69 
Rictschcl,   332 
Rillict,  8,    IS,  203,  205 
Rimplcr,  201 
Rindfleisch,  v.,  152,  173 
Ritschel,   153,  340 
Ritter,  2,  10,  12,  iG,  70, 

182,     294,     298,     305. 

322 
Riviere,  383 
Robbi,  188 
Robertson,    109 
Robin,   332 
Robin,  A.,  52,  160,  330. 

343,   414 
Rohng,  332 
Romer,   34,   254 
Roepke,  264,    282,   379 
Rohlff,    151 
Rohmer,   P.,   380 
Rohrer,    194 
Rokitansky,   8 
Rolleston,    206 
Rollier,  342,  343 
Roily,   257,   258,  262 
Roques,    195 
Rosenberg,  43 
Rosenberger,    141,    418 
Rosenstern,   53,  236 
Rosenthal,    143 
Roth,   64,  77,    188,   384 
Rothholz,   200 
Roux,  103,   195,  242,  2()3 
Rubino,  213 
Ruck,  v.,   381 
Ruediger,  391 
Ruete,   3,   255 
Ruge,    140 
Rumpf,    103 
Runge,    151 
Ruppel.  34 
Rupprecht,    145 
Russ,    258 
Russel,    337 

S. 

Saalfeld,  390,  392 
Saathoff,  381 
Sabourraud,    152 
Sacaze,  86,  140 
Sachs,    1 55 


Sanger,    303 

Sahli,   378,  3ii2 

Salge,   18,  08,  249,  20. 

3<>7,  3^3 
Saliycr,  249 
Saikowski,    L.,   373 
Salic,    242 
Salmadc,  8 
Salo,  257 
Salomonsohn,  9 
Sanchez,    153 
Santlus,    331 
Sapcschko,  393 
Sappcy,    12O 
Sarfcis,  418 
SarklofT,  384 
Sattcrlee,   256 
Satllcr,   13,  72,  86 
Schablowski,    282 
Schiifcr,  384 
Schall,    241 
Schanz,    418 
Schaumann,  39O 
Scheibner,    v.,    140,    141 
Schelbe,  381 
Schenk,  256,  258,  2G1 
Schenker,  384 
Schepclern,  365,  366 
Scherenberg,  403 
Schern,  148,  246,  250 
Scheven,   v.,   246 
Schey,  258 

Schick,  239,   242,   255 
Schick-John,   258 
Schidacki,    188 
Schiele,    139 
Schiff,  397 
Schiller,   417 
Schimmelbusch,    76 
Schkarin,   249 
Schlassberg,    188 
Schleisner,  257 
Schlencker,    86,    119 
Schlenker,    140 
Schlesinger,    140 
Schlieferowitsch,    143 
Schliephake,   77 
Schlippe,  258,  263 
Schlbmpert,   152 
Schlossmann,     92,     96. 

135,     261,     275,     284. 

379,  380,  381 
Schliiter,   49,    160 
Schmalfuss,   135 
Schmidt,   64,   2or 
Schmidt-Xothmann.  257 
Schmidt-Rimpler,  410 
Schmiegelow,   390 
Schmincke,    330 
Schmorl,    152,   153 
Schnoller,    384 
Schonborn,    157 
Schonfeld,    188 
Schongen,  in 
Scholtz.  398 
Schottelius,  33 


514 


INDEX    OF    AUTHORS 


Schottmiiller,  24S 
Schreiber,  154 
Schroder,   38,  255,   261, 

262,  381 
Schroder,  G.,  40,  270 
Schrotter,  v.,  102 
Schrumpf,   152,  256 
Schubert,    261 
Schuchardt,    10,    11,    87- 
Schiiller,   9,    170,  412 
Schiippel,    8,    175 
Schiitz,     137,     I3Q,    165, 

200 
Schulte,  247 
Schultze,  Qi,   393 
Schulz,   200,   248,  290 
Schurmann,    186 
Schwabe,   373 
Schwartze,  198,  391,  408 
Schwarze,  393 
Schweinitz,  de,  38 
Sedlitzky,    369 
Socman n,    247 
Schlbach,   55 
Seiffert,  256,  258,  261 
Seige,    151 
Seller,   218 
Selenkow,   207 
Seligmann,  256 
Seller,  384 
Senator,    53,    236,    332, 

333<.  386,  387 
Sendziak,    195 
Senger,  253 
Sequeira,   261 
Sergent,  236 
Sermasi,    11 1 
Seyacker,  257 
Shaw,   241 
Shiga,    105 
Siebenmann,   198 
Siegenbeck,    van    Heu- 

kelom,  256,  261 
Siegert,    154,    253,   265, 

374 
Sicgrist,  256,   261 
Sikemeier,    384 
Silvestri,  247 
Simmonds,   150 
Simon,  52,  142,  195,  384 
Simon,  J.,  206,  238 
Simon,   Robert,  342 
Sinding-Larsen,         363, 

365,   366 
Sippel,  365 
SiracoflF,   239 
Sircna,   150 
Sittler.    183 
Sitzenfrey,    151 
Skutetzky,  246 
Sluka,   239,   242 
Smith,  38,  42,  382 
Smith,  Eustace,  241 
Smith,     Theobald,     28, 

31,   270 
Sobernheim,   195 


Sobotta,  40,    105,    160 
Sbllner,    188 
Sohler,   417 
Soltmann,    15,    59,    60, 

160,     217,     252,    378 
Sommerbrodt,  376 
Soxhlet,   288 
Spano,   150 
Speck,  40 
Spengler,     30,     31,     40, 

1O8,  248,  270,  384 
Spieler,    187,    188,    190, 

191 
Spiethoft",   392 
Spitzmiiller,     367,     407, 

410 
Sprengel,    133,    145,   i;^ 
Spronk,  38,  39,  loi,  114 
Squire,    Balmanno,   393 
Stadelmann,   256 
Staubli,  54 
Stange,   iii 

Starck,  87,  142,  143,  415 
Stark,  v.,  105 
Staub,    200 
Steigenberger,  86 
Stein,   54,   128 
Steindorflf,  256 
Steiner,  240 
Steinitz,  51,  53,  298 
Steinwand,    412 
Stephenson,  200 
Sternberg,  244,  340,  343 
Sticher,  417 
Stiel,  404 
Stiller,   160 
Stintzing,  416 
Stirnimann,    134 
Stoeckel,   153 
Stohr,    140 
Stolting,  86 
Stoerk,    194 
Stoll,  242 
Storen,    157 
Stowell,    112 
Strandberg,  396 
Strassmann,  140 
Strassner,  93,  94 
Straub,    13 
Straus,    153,   384 
Sturm,  214 
Sturmann,  403 
Stuurmann,  40 
Suchannek,    127,    142 
Sutton,   190 
Swieten,   van,  7 
Sylla,   410 
Symoneaux,  186 
Syms,  413 
Szaboky,    384 
Szurek,  384 

T. 

Tait,   206 
Takewossianz,    272 


Takeya,   81,  89 
Tangl,   64,   201 
Tante,  37 
Tanzer,  65 
Tappeiner,  90 
Tarchctti,   141 
Taute,   28,   266 
Tedcschi,    106,  254,  274 
Tendeloo,    91,    96,    loi, 

102,     no,     121,     123, 

125,     126 
Tenneson,  187 
Tcrichell,   249 
Termin,  262,  263 
Teubert,  375 
Tezner,  257 
Thibierge,   188,   190 
Thiemann,  242,  415 
Thiercelin,    153 
Thiersch,  393 
Thilmann,   243 
Thom,    156 
Thomesco,    249 
Thomsen,   265,   284 
Thorspeken,  384 
Tice,   261 
Tietze,  417,  418 
Titze,  28,  36,  37,    1 14 
Tixier,   142 
Tobiescu,  261 
Topfer,  382 
Toeplitz,    380 
Toledo,   153 
Tonzig,    106,    108 
Torday,    v.,    249 
Trautmann,  142,  195 
Treplin,  365 
Treves,  413 
Treupel,  256 
Troje,    39 
TromsdorfF,   271 
Trousseau,  256,  391 
True,   200 
Trumpf,   243 
Tscherning,   39,   87 
Tschlenow,  396 
Tuffier,  418 
Turan,    417 

Turmann-Leonardo,37i 
Turner,  142 

U. 

Uchermann,  86 
UflFelmann,    in,  361 
Uffenheimer,  64,  83,  90, 

04,   97,    179 
Uffenorde,   142 
Uhlenhuth,  11,  245,  246 
Uhthoff,   200 
ITllmann,  384 
Umber,  256 
Ungar,    143 
Unna,  65,  139,  183,  281. 

389,    300,     395,     396 
Urbantschitsch,    407 


INDEX    OF    AUTMOKS 


515 


Vagedcs,  27 

Vall6e,   114,  256 

Vanstccnberghc,  64,  qi 

Variot,  204,  239,  41 1 

Varrcntrapp,  340 

Vecchi,  dc,  Sy 

Vci(jl,  3y4 

Vclpcau,    7,    15,   63 

Ventura,  54 

Verge,   3fj6 

Verneuil,  418 

Vernier,   253,  257,   260 

Verotti,   iqo 

Verth,    zur,   417 

Vestea,   105 

Vidal,   384,  303,   399 

Vidccky,   200,   393 

Vignal,  153 

Villaret,  151,   159 

Villemin,  8,  g,  27,  28 

Virchow,  5,  6,  7,  8,  48, 
49,  57,  60,  62,  74,  1 10, 
167,  174,  175,  177, 
179,     214,    2i6,     278 

Vloet,  van  der,  ■},T] 

Volker,  207 

Vogel,  v.,   105,  223 

Vogelmann,  416 

Vogt,   52 

Volk,  254 

Volkmann,  12,  87,  133, 
158,    182,    X95,   393 

Volland,   2 


Waetzoldt,  244 
Wagener,    no 
Wagner,    78 
Wagner,  H.,  201 
Walb,  86 
Waldmann,  391 
Wallerstein,  384 
Wallis,  206 
Walsham.   140 
Walter,    187 
Walther,   151 
Warthin,   152,   177 
Washburn,   40,   270 
Wasmuth,  76 
Wassermann,   245,  250, 

265 
Wassermann,  M.,  103 
Watt,   III 


Weber,  20,  28,  31,  ZZ, 
34,  35,  3^',  7,7,  38,  39, 
40,  41,  4-2,  43,  47,  08, 

99,  102,  103,  108,  1  ;2, 
114,  117,  ><J8,  231, 
250,  266,  267,  270, 
271,    273 

Weber,  A.,    112 
Weber,   Hermann,  331 
Wedd,  255 
Weekers,  200 
Wehiner,   315 
Wehrli,  248 
Wcichsclbaum,    98,    99, 

124,    168,  207 
Wcickcr,  381,  384 
Weigert,   51,    53,   67 
Weigert,   R.,  341 
Weihrauch,  247,  384 
Weil,   262 
Wein,   384 
Weinberg,    156 
Weintraut,  384 
Weishaupt,  244 
Weiss,  247,  248 
Weleminsky,      95,      99, 

100,  122,    123 
Werndorff,  243 
Werner,   350 
Wertheim,    189 
Werther,   397,  398 
Wesener',  27,  83 
Westenhoeffer,  38,   122, 

123,  124,    143 
W^estermayer,    151 
Westphal,  384 
Wetterer,  412 
Wetzell,  260,  263 
Wex,    102,    142 
White,  6,  155,  157,  302, 

378 
White,  The,  48,  150 
Wichmann,     396,     397, 

398 
Widerhofer,     203,     207, 

240 
Wideroe,    262 
Wiens,   256,   261 
Wiesner,   290 
Wild,    145 
Wilde,    409 
Willson,    263 
Wilms,  264,  412,   418 
Wilzcur,  261 
Wimmer,  332 
Winkler,   102,   257 


Wiiitcrniiz,    170,  371 
Win  lis,    247,   24H 
Wit /.(;].    O.,   393 
Wil/.inger,   29O,   392 
Wluitbeck,  3O7 
W oh I berg,   384 
Woblgc:muth,  3,  4,   13? 
Wolbach,  270 
Wolfrtr,    239 
Wolff,   186,  248 
Wolff,  Max,  90,  2r4 
Wolff- Kisncr,   250,  251, 

253,   255,  2O1,   264 
Wollstcin,  152 
Wood,  104 
W'oodcork,  256 
W^fodruff,    J 55 
Wreden,    198,   417 
Wright,    142,  371 
Wrisberg,  204 
Wroblewski,  86 
Wunderlich,  3 
Wyssokovvitsch,    11,    26 

X. 

Xylander,  245 

Y. 

Yong,    de,    31,    34,    35, 
39,   40,   286 


Zahn,    no,   247 
Zanconi,    141 
Zarnike,   142 
Zaufal,    194 
Zebrowski,   242 
Zenker,  207 
Zickgraf,    142 
Ziegler,    176,   264 
Ziehl,    189,   247,   248 
Zieler,    185,     187,     i8q. 

253,    264 
Zilgien,   155 
Zimmermann,   43,    230 
Zinsser,  397 
Zippelins,    105 
Zoppritz,  261 
Zucker,  2,2)'i 
Zumbusch,   188 
Zumsteeg,  242.  382 
Zuntz,  329,  332 
Zuttinger,    244 
Zwick,   36 
Zwillinger,  142 


John  Bale,  Sons  iS;  Damelsson,  83-91,  Great  Tiichfield  Street    London.  \V. 


DATE  DUE 

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